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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Pedro BenIto AId V8IqLM!IZ
CO~TY DutdtIlSS
CITY/TOWt;l ~nger
DISTRICT 1368
NUMBER
REGISTER 'Sf
NUMBER
1. A. FULL NAME
FIRST
CURRENT SURNAME
MIDDLE
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER
N Y DuIchoIs
2 RESIDENCE A. B-
(STATE) J (COUNTY)
C CHECK ONE~TY c:r OWN 0 VILLAGE
AND
SPECIFY
D STREET ADDRESS 2811fsk16 Aven.8, AI1 2 ZIP
12580
YES r'! NO
/1882
YEAR
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
06 /28
MONTH
3 A, AGE 20
38. DATE OF BIRTH
DAY
l-
s;:
<C
C
LL
LL
<C
4 EMPLOYMENT
A. USUAL OCCUPATION ,.,. ~
B. TYPE OF 'NDU~'~ st8r AUIOI'nGIIYe
5. PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A, NAME JdIo AbrI 0IeIIs
B COUNTRY OF BIRTH Ecuedar
7 MOTHER
A MAIDEN NAME GlorIa VesQUelZ
B, COUNTRY OF BIRTH Ecuador
8, NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO&CE CIVIL AN~LMENT
DE~H
B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
..
I
~~..4.~if
L D SUPPLEMENTAL FILE
FROM THE BRIDE
N8taIa A AbrIl
-.J
11. A, FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE AbrIl
(OPTIONAL. SEE REVERSE)
D, SOCIAL SECURITY NUMBER
12, RESIDENCE A, NY B- DutcI\el!Ia
(STATE) J (COUNTY)
C CHECK Ol'f.~_g_ CITY IT TOWN 0 VILLAGE
~~~CIFY VYIIpptIg8r
0, STREET ADDRESS 2418 ~ 8 0 ZIP 12590
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r! NO
06 /14 A979
YEAR
13. A, AGE 23
13,B. DATE OF BIRTH
MONTH
DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Haln:fr:llller
8. TYPE OF INDU~'1ESS ROC8I1S 58IOn
15, PLACE OF BIRTH cuador
(CITY, STATE/COUNTRY IF NOT USA)
16, FATHER
A. NAME Ivan AbrI
8. COUNTRY OF BIRTH i:CUICIDr
17. MOTHER
A. MAIDEN NAME Mercy Calle
8. COUNTRY OF BIRTH EcuIdor
18, NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL AN~LMENT
DE1)H
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
D, ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
18T 0 0 1 8T 0 [J
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marria~tate, Il '
21SIGNATUREOFGROOM~ 'If'E I/; t1 'NO\c..\C>. \ ~~/)'( ';';" \
USE CURRENT NAME
DATE 04JD8I2003
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license" autl'i~~ 1he marriage in New York State of the bride and groom named above by any person authorized
Relations LlfN ~11 to per1'orrtll"arriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY,
,,, 0 IYchecked, this license is to be used only for the purpose of a second or subsequent ceremony.
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by New York Domestic
TIME
25. A. SOLEMNIZATION PERIOD BEGINS
MONTH
YEAR
.~ 04IDBI2003
FIIIIs, NY 12590
CITY OWN STATE ZIP
27 TYPE OF CEREMONY
AM
01:13PM
04
28, PLACE WHERE MARRIAGE OCCURRED
...
DAY YEAR 00 RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A. STATE NEW YORK B, COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF [] TOWN OF [J VILLAGE OF
': '\
29, OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
STREET
30, WITNESS TO CEREMONY
CITYITOWN
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
SPECIFY
STATE
ZIP
31 WITNESS TO CEREMONY
NAME ~PRINT)
SIGNATURE ~