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8TATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rafael Sumano
.MIDDLE CURRENT SURNAME
23. ~::~fT~~~DO~N-Po~~OJ!~ J(f!~~~~E. DATE 03(25'2003
This license authorizes the marriage in New York any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies with New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
]
COUNTY Dutchess
C;TYfTOWN Wappint,ter
S~J:~W 1368
~5~~~R 27
1. .A. FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SDCIAL SECURITY NUMBER
2. RESIDENCE A. N~r ork
c. CHECK ONE 0 CITY [!'" TOWN
AND W .
SPECIFY app'nger
D. STREET ADDRESS 4 K White ~ate Drivt'! ZIP 1 ~~QO
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 33 3B. DATE OF BIRTH MJAl / 3l / J&69
4. EMPLOYMENT
A. USUAL OCCUPATION
B. TYPE OF INDUSmy OR BUSINESS Olympic RE'~fal Ira""
5. PLACE OF BIRTH ~m~'IMN&jZ, Oaxaca
6. FATHER
A. NAME Fortunato ~lJm$!lno ni$!17
B. COUNTRY OF BIRTH ft4pXiC(JI
7. MOTHER
B. ~e~~
o VILLAGE
A. MAIDEN NAME MaRa 09 109 Ange'eE Jimenez
B. COUNmY OF BIRTH Mexico
8. . NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
o
o
o
(2) 0 DEATH
B. HOW DID'LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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) (CrrY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
W
en
z
W
o
:J
~
{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
,
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Marci J Acevedo
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAMl:), IF DIFFERENT
C. SURNAME AFTER MARRIAGE ~I Jmano
(OPTIONAL. SEE REVERSE)
D. SDCIALSECURITYNUMBER 121-58-~7QO
12. RESIDENCEA. N%WTlnrk B. ~Mt~~~
C. CHECK ONE 0 CITY [JII"rOWN 0 VILLAGE
AND till .
SPECIFY vvappfflger
D. STREET ADDRESS 4.J.{ White ~ate nrive ZIP 12~Qn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES [J' NO
13. A. AGE 30 13.B.DATEOFBIRTH M~ /Q:1y ~~
14. EMPLOYMENT
ON P\/bmagp.r
B. TYPE OF INDUSTRY OR BUSINESS Mar~Jot8Ir~
15. PLACE OF BIRTH P~H911~~ _ York
(C , I MOT
16. FATHER
A. NAME Anthony Ar.p-vprJo
B. COUNTRY OF BIRTH II 5 A
17. MOTHER
A. MAIDEN NAME Judith V\.l.eber
B. COUNTRY OF BIRTH I I ~ A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
(2) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
2D. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CrrY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
22. SIGNATURE OF BRIDE ~
TIME
MONTH
YEAR
MONTH
YEAR
IP
'11 :51~~
26 200 05 24 2003
28. PLACE WHERE MARRIAGE OCCURRED
03
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A
27. TYPE OF CEREMONY
AR 0 M RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
A. STATE NEW YORK B. COUNTY ha:Jrk,C'('
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY ~fl J6: fR5f f,'5H M't.L
ITLE ~tUJW{ ~ Ilc fJlt.J'es'f
ATE IJpAi I 6 ~ 00 ~
IV /
NAME (PRINT)
SIGNATURE ~