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COUNTY [)~IM5&
CITYfTOWN '.Nappinger
~:;J~~C: 1368
~G~I~J~R 26
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
1. A. FULL NAME
~n A. O~ENT SURNAME
11. A. FULL NAME Qilru:a Ins nAril!!!2..
FIRST ~~ . r_''-1::lJRRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Perez
c. SURNAME AFTER MARRIAGE nr+-a
(OPTIONAL. SEE REVERSEFnvva
D. SOCIAL SECURITY NUMBER 067 -7&-0208
12. RESIDENCE A. N 'tTATE) B. ~I
C. CHECK ONE 0 CITY ~TOWN 0 VILLAGE
AND 'Na' .
SPECIFY 11 ppenger
D. STREET ADDRESS 42_West Meln Str.eet ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES fi NO
M~ /1Bv -1~
FIRST
lL
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 574 94 8459
B. ~r-d
o TOWN 0 VILLAGE
2. RESIDENCE A. ... A
"''lS''A TE)
C. X~6CK ONE '" CITY
SPECIFY Fall River
D STREET ADDRESS 98 John str.-t ZIP 02721
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
MOW / 25 / W79
13. A. AGE 22
14. EMPLOYMENT
13.B. DATE OF BIRTH
3. A. AGE 23
4. EMPLOYMENT
38. DATE OF BIRTH
A. USUAL OCCUPATION Military
B. TYPE OF INDUSTRY OR BUSINESS U. S. "./mY
5. PLACE OF BIRTH ~B~ JII}lnd
6. FATHER
A USUAL OCCUPATION Military
B. TYPE OF INDUSTRY OR BUSINESS Air Guard
15. PLACE OF BIRTH Elf~AuN8N;Y;wJF
16. FATHER
A. NAME Alfred Ortega
B. COUNTRY OF BIRTH U S ^
7. MOTHER
A. NAME Thomas Perez
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Olga Mllagros Suar-ez
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
A. MAIDEN NAME Almerlend8 Pimentel
8. COUNTRY OF BIRTH Portugal
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
8. HOW DID LAST MARRIAGE END? (3) [ilf'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? net / "'6 / 'YIIV'i
MONTH - OAt ..",."....-
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
100
8. HOW DID LAST MARRIAGE END? (3) []lIbIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? 08 / 1Q /?IVV\
. MONTH ofJ,r ~
D. ARE ANY FORMER SPOUSE(S) ALIVE? u,WES 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
1ST 0811612000 8 Peso Co., Texes
2ND
3RD
4TH
I, being duly sworn, depose and say, that to
as to my right to enter into the marriage st
21. SIGNATURE OF GROOM ~
o [lI' 1ST 08I18f2000 EI Paso CO.. Texas
o 0 2ND
o 0 3RD
o 0 4TH
Y knowledge and belief that the information I provided is tr
0; 0
o 0
o 0
o 0
re that no legal impediment exists
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State he bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New Yor 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
{ } ".'''~
. , ~,
SEAL SIGNATURE ~
. MAILING ADDRESS
'-.,,-I. .
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
24 2003
DATE 03ll5f2Q03
by New York Domestic
MONTH
YEAR
YEAR
MONTH
DAY
TIME
DATE
03l25f.2Q03
10:33~~
03
26
05
ZIP
1 tl'cIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~VILLAGE OF
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)
SIGNATURE ~