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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JI! S. Rey~URRENT SURNAME
COUNTY[)~~
CITYITOWN Wappinger
~lTJ~~~T 1368
~Q~~J~R 36
1. A. FULL NAME
FIRST
Q.
N
B BIRTH NAME, IF DIFFERENT
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kat.ta~!,e M. Bai~ENT SURNAME
-.J
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 075-S4~5363
2. RESIDENCE A. N v B. W'"""-s
13TATE) ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND n &..a..-...-"
SPECIFY F"'OIJgu-.-le
D STREET ADDRESS 5lf1 Shear. Road. Lot 69 ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..tJ NO
Ja /1Zy / 'WZ9
3. A. AGE23
4. EMPLOYMENT
3B. DATE OF BIRTH
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE g-.es
(OPTIONAL. SEE REVER~V'J"
D. SOCIAL SECURITY NUMBER 1 Q8..7&-8803
12. RESIDENCE A.N V B. 01 rtrh~
~TATE) ~1'Tj'
C. CHECK ONE 0 CITY .., TOWN 0 VILLAGE
AND n &..kee'
SPECIFY ....ougJ 1 psle
D. STREET ADDRES~ Sbeaf.e Road. lot 69 z1P12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
QlH /.!QAY f9fMR
13. A AGE18
14. EMPLOYMENT
13.B. DATE OF BIRTH
A USUAL OCCUPATION Construdion VVorker
B. TYPE OF INDUSTRY OR BUSINESS Hudson V.alley Pavement
5. PLACE OF BIRTH~ ~ 9~ RJco
,If. ffY F
6. FATHER
A. NAME Ruben Reyes
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME MadellAe !\viles
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A USUAL OCCUPATION Assistant Manager
B. TYPE OF INDUSTRY OR BUSINESS Me Donald's
15. PLACE OF BIRTH~gu~~~ York
16. FATHER
A. NAMEWllillm BIIiley, Jr.
B. COUNTRY OF BIRTrtJ S A
17. MOTHER
A MAIDEN NAME Carol Behnke
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
(2) 0 DEATH
o
o
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
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
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
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1ST 0 0 1ST
2ND 0 0 2ND
~D 0 0 ~D
~ 0 0 ~
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is tr e
as to my right to enter into the marriage state
o 0
o 0
o 0
o 0
d that I declare that no egal ilJlpediment exists
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{ SEAL}
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NAME (PRINT)
21 SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWOR~
SIGNATURE OF TOWN OR CITY CLE DATE
This license authorizes the marriage in New York State of th bride and groom named above by any person authorized by New
Relations Law ~11to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
TIME
MONTH
DAY
YEAR
MONTH
YEAR
ZIP
09:55 ~~ 04
07 2003
09
2003 06
1~
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. COUNT~1t~
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
CJ ""'~, ~ W"'O, ~,",G'~. IL
fjPECIFY ~Am::I\.61'a.& ~
NAME (PRINT)
SIGNATURE ~