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1. A. FULL NAME
STATE OF NEW YORK I
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Lf4tJRWO ~ R8\Jll ~ N!lVi1Jf/ 11. A. FULlNAME
FIRST MIDDLE CURRENT SURNAME
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
CCU,4TY Dutche!'l~
CITYnOWN Wappinger
~~~~~cJ 1 ?,f,8
~5~~J~R 4
L 0 SUPPLEMENTAL FILE
FIRST
FROM THE BRIDE
Aida r= FI~avp.d
MIDDLE eURRENT SURNAME
II. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Rom E't'o
C. SURNAME AFTER MARRIAGE F:1~ri NIt"~ 1#
(OPTIONAL. SEE REVERSE) J<
D. SOCIAL SECURITY NUMBER 1 OO-RO- 7408
12. RESIDENCE A. ~~~ Yod( B. ~e~s
C. CHECK ONE 0 CITY 0 TOWN 0 \MI..LAGE
AND
SPECIFY Wappingp.r~ F RIIR
D. STREET ADDRESS 1'2, ~nnih R"m~j:1r; A\S"nnp. ZIP 11C,Q(l
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 'lltl:s 0 NO
13. A. AGE <11 13.B. DATE OF BIRTH MON~J / DiP / 1~1
"-
N
II. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
O. SOCIAL SECURITY NUMBER
2. RESIDENCEA.~~ YOI"Ir B. (~hess
c. CHECK ONE 0 CrN 0 TOWN 0 ""LLAGE
~~CIFY WRppingp.rR FRIIR
D. STREET ADDRESS 1"), ~nldh Rp.m~p.n Avp.nueZlP 17~qn
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORI'ORATED vILLAGE? 0 'l/'!:s 0 NO
3. A. AGE 32 3B. DATE OF BIRTH ~ / OA97 / ye197
4. EMPLOYMENT
A. USUAL OCCUPATION r=nn~trur.iinn
B. TYPE OF INDusmy OR BUSINESS Npw Y()rll' Cnrpnn~Un",
5. PLACE OF BIRlli (d~~ IF NOT USA)
6. FATHER
A. NAME pp.tp.r Nl=l\Sp.dR
B. COUNTRY OF BIRTH ~rg~ntifl~
7. MOTHER
A. MAIDEN NAME CSFFR8n Fig8~a
B. COUNTRY OF BIRTH .a.rgentiHs
8. NUMBER OF llilS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNUUMENT
100
B. HOW DID lAST MARRIAGE END? (3) 0 lllfORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? g~ 21 / "098
MONTH DAY yEJ;R'"
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 yt!!; 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
14. EMPLOYMENT
A. USUAL OCCUPATION flnri!':t
B. TYPE OF INDUSTRY OR BUSINESS Self - Emplo)'E'(f
15. PLACE OF BIRlli lChf'MmNTRY IF NOT USA)
16. FATHER
A. NAME frnil~n Rnm....rn
B. COUNTRY OF BIRlli Ecuador
17. MOlliER
A. MAIDEN NAME CaRR en Paez
B. COUNmY OF BIRTH Ecuador
18. NUMBER OF llilS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
u:
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DEATH
000
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE{S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNUUED, PROVIDE lliE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STA1EICOlINTRY, IF NOT USA) '. SELF SPOUSE
o 1ST C3fZ7f1SaS Ouce;'1, Ne~.il Y:oi'i\ 0 0 .,
o 2ND 0 0
o ~ 0 0
o 4TH 0 0
belief that the information I provided IS true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE ~ (/)~~~t
USE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEF
SIGNATURE OF TOWN OR CITY C DATE . 00'3
This license authorizes the marriage in New York Stat of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used onl for the urpDse of a second or subsequent ceremony.
24. TOWN OR CrN CUERK 25. A. SOLEMNIZATION PERIOD BEGINS
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21. SIGNATURE OF GROOM ~
1ST
2ND
3RD
4TH
I, being duly swom, depose and say, that
as to my right to enter into the marriage
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YEAR
MONTH
YEAR
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{ SEAL }
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22 2003
TIME
MONTH
NAME (PRINT)
01/.21 '200
01
22
20 3 03
28. PLACE WHERE MARRIAGE OCCURRED
STATE NEW YORK B. COUN~/ ~~ ~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY fA) €> ffl ~ el("
NAME (PRINT)
SIGNATURE ~