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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~,~~[J P. Pinta~RRENT SURNAME
COUNTY n'ltr.hp~~
CITYfTOWN \Af;"'rrinopr
~~J~~c~ 1368 .
~5~~J~R 2
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 066-66 1959
2. RESIDENCE A. N. v B. nllt,,'hess
(S'I'"ATE) ~
C. CHECK ONE 0 CITY 0 TOWN ~ VilLAGE
AND A" ~
SPECIFY , applngers r ails
D. STREET ADDRESS 29 I-lillside A\lpnllf> ZIP 1 ?~9(l
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VilLAGE? I!I" YES 0 NO
MO~~ / o1~ / Y~1t7
3. A. AGE 31
4. EMPLOYMENT
38. DATE OF BIRTH
A. USUAL OCCUPATION Cabinet Maker
B. TYPE OF INDUSTRY OR BUSINESS Scanga Architectural \^'d\/'IIQ
5. PLACE OF BIRTH ~~I~!oUNTRY IF NOT USA)
6. FATHER
'A. NAME Julio Pintado
B. COUNTRY OF BIRTH Ecuador
7. MOTHER
A. MAIDEN NAME Cnaoiola Auquilla
B. COUNTRY OF BIRTH Ecuador
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
100
B. HOW DID LAST MARRIAGE END? (3) IYDlVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 04/"'0 / ..,n01
MONTH OAr YEM'
D. ARE ANY FORMER SPOUSE(S) ALIVE? [Y'fES 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
5TATE FilE NUMBER
(THIS SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
r . A ~ Id
- 'iiQIV'l . 0 ~ENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Pintado
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. N ~ATE) B. q~,s
C. CHECK ONE 0 CITY 0 TOWN [il'VILLAGE
~~CIFY '^'appingers Falls
D. STREET ADDRESS ?q I-lil'sirlp A\lpnlIP ZIP 1 ?~qn
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? I!I" YES 0 NO
13. A. AGE 25 13.B. DATE OF BIRTH M~ / ~~ /12:,.17
14. EMPLOYMENT
A. USUAL OCCUPATION House-wife
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~AAB!oUNTRY IF NOT USA)
16. FATHER
A. NAME Manuel Roldan
B. COUNTRY OF BIRTH Ecuador
17. MOTHER
A. MAIDEN NAME ;'\na Chavez
B. COUNTRY OF BIRTH Ecuador
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
o
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
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 5POUSE
o
o
o
I
1ST 04/20/2001 'Nestchester Co., N Y
2ND
3RD
4TH
I, being duly sworn, depose and say, th
as to my right to enter into the marriag
o [iI' 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belie that the information I provided is true and that
23. SUBSCRI8ED AND SWORN TO
SIGNATURE OF TOWN OR CI CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law ~11 to 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 urpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL}
'-v-I
01/09'2003
by New York Domestic
TIME
MONTH
AM
PM 01
10
200
03
10 2003
SIGNATURE ~
MAILING ADDRESS
..,
ST
~~~R~~Ri~~~ 10~O~~~N:,zl~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME M. DAY YEAR
DATE AND AT THE TIME AND
PLACE INDICATED. g: 35 PM 02
29. OFFICIANT SUSAN J. MILLER
NAME (PRINT) .
SIGNATURE ~ ' ~N')Q/v\.
MAILING ADDRESS
YEAR
MONTH
YEAR
A E
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
14
03
~IAGE OFFICER
TITLE
1 Q( CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYDutchess
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF XI TOWN OF 0 VILLAGE OF
SPECIFY Poughkeepsie
ROAJ1,
DATE FilnWABY 11, > 2003
NWATtORK 1260~IP
31. WITNESS TO
SIGNATURE~
DOH-9S (11/98)
NAME (PRINT)
SIGNATURE ~