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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Ang~ii~lben GO'iiW~SURNAME
1ST 0 0 1ST 10/05/2001 Gwinniltt Co., Georgia 0 [S"
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and sa . that to the best of my knowledge and be lef that the information I provided is true and,.! at I declare that nff legal ~~-?"ent ejlists
as to my nght to enter into the m I ge state.'--'/'.'. ~ ~ Ctf!IJ.
21. SIGNATURE OF GROOM ~! ,"/ t!!' . 22. SIGNATURE OF BRIDE ~ ::;7') ~ ~1 ~E ~
23 SUBSCRIBED AND SWORN TO BEF E ME ' /"M
SIGNATURE OF TOWN OR CITY CLERK ~ DATE n 1 tn? I?nn~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 purpose of a second or subsequent ceremony.
{ ~ } ~:;~;:IO~R CITY CLE,RK ~ 25. A. SOLEMNIZATION PERIOD BEGINS
_ ~' TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ . DATE 01'02'2003
MAILING ADDRESS' ., 10'47 AM
'-v-I ST~Q Middlebush Rd, WappJ~NFall'S, N~ATE12590 ZIP . PM 01 03 200 03 03 2003
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~ 28. PLACE WHERE MARRIAGE OCCURRED
THE MARRIAGE OF THE PER- ~
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 CIVIL EW YORK ~ 11M
DATE AND AT THE TIME AND A. STATE N B. COUN 1/ ,~~
PLACE INDICATED. 9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AN~ECIFY)
o CITY OF &;il""TOWN OF 0 VILLAGE OF
SPECIF'.uJ tN?I'J Nt t f"Z.,....
COUNTY DI ,tc"es~
CITYfTOWN \M::lpringE>r
~~J~~~T 1368
~5~~J~R 1
1. A. FUU NAME
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUM8ER 111 66 0520
2. RESIDENCE A. G~"Iia B. '1lWj~ett
c. CHECK ONE ,jZJ CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Dacllla
D. STREET ADDRESS 161~ Fnrt pprry \N~y ZIP ~on19-fl7
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VIUAGE? 1lI YES 0 NO
3. A. AGE 22 3B. DATE OF BIRTH M~ / ~l / y1.~80
4. EMPLOYMENT
A. USUAL OCCUPATION ~s5iembly
B. TYPE OF INDUSTRY OR BUSINESS GE'neral Motor'S
5. PLACE OF BIRTH ~RJ~b~9~';fJl ~rw York
6. FATHER
A. NAME AngQI ManuQI GonzSllill
B. COUNTRY OF BIRTH Cuba
7. MOTHER
A. MAIDEN NAME Maria Lourdes Ruiz
B. COUNTRY OF BIRTH Cuba
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
DEATH
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L D SUPPLEMENTAL FILE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
YEAR
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FROM THE BRIDE
11. A. FULL NAME FIRST LE'SUI~olynette Cti?~~ENTsuRNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Cobert
c. s~S~~\':SN~~~~~t~~O~~s~onzale.z
D. SOCIAL SECURITY NUM8ER 521-55-12"39
12. RESIDENCE A. GEj9[sia B. GfJWiW'tt
C. CHECK ONE ii!'I CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Da~llla
D. STREETAODREss1flp Fnrt pprry Way ZIP 30019-6'
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIUAGE? 1Z'I YES 0 NO
13. A. AGE 32 13.B. DATE OF BIRTH MOOH / ~ Pj~2.P
14. EMPLOYMENT
A. USUAL OCCUPATION HOll'selAlife
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~JfilrmJ2~my ~LM~lr:a
16. FATHER
A. NAME Leslie Leonard Cobert
B. COUNTRY OF BIRTH I I S A
17. MOTHER
A. MAIDEN NAME Spellmyra Stobldem'lre
B, COUNTRY OF BIRTH/j S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
1
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B. HOW DID LAST MARRIAGE END? (3) ~DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 10 / n5 / ?nR01
MONTH o'J!i mF
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ES 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
YEAR
SIGNATURE ~ .