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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
f ernando Palacios
I ~ur (;::;;~~~;E:;) I
L 0 SUPPLEMENTAL FILE -.J
FROM THE BRIDE
Ximena Alexandra Andrade
rjllfrl-'eL'"
COUNTY L.. \.i .vi t ~h.'
CITYITOWN \/Vappinger
DISTR.(~'q ",68
NUMBEcR ~
REGISTER'172
NUMBER
A FUll NAME
CURRENT SURNAME
FIRST
MIDDLE
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL SEE REVERSE09'1 7" c'"}'l t;).
D SOCIAL SECURITY NUMBER .".. ".. U.'J...' '..l
2 RESIDENCE A. New York B. Dutchess
C CHECK ONE (STAg) CITY '6 TOWN 0 VilLAGE (COUNTY)
~~~CIFY Wa in er
u All Angels Hili Road ZIP 12590
D. STREET ADDRESS
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VillAGE? 0 YES'6 NO
/13 /1953
DAY YEAR
.1')
3. A. AGE"1"~1
11
MONTH
38. DATE OF BI RTH
4. EMPLOYMENT
A USUAL OCCUPATION Construction
8. TYPE OF INDUSTRY OR BUSINESS Self.. Em ployed
5. PLACE OF BIRTHEcuador
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME l uis Palacios
B. COUNTRY OF BIRTH Ecuador
7. MOTHER
A. MAIDEN NAME Y olamia Del Pozo
B. COUNTRY OF BIRTH FcuadQf
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
'1
8. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) i"i' DEATH
C. DATE LAST MARRIAGE ENDED? D4 / 14 / 1991
MONTH 'DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES '6 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
11. A FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Palacios
(OPTIONAL. SEE REVERSE) .
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANew York
(STATE)
c. CHECK ONE 0 CITY
~~~CIFY Wappinqer
D. STREET ADDREss20B All Angels Hm Road
B. Dutchess
I":i TOWN 0 VILLAGE (COUNTY)
"1 ") L. i')f't
ZIP 'L.....JU
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VillAGE? 0 YES l"i NO
13 A AGE33 13.8. DATE OF BIRTH 06 /19 xf.H19
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION La\'I,'Yer
B TYPE OF INDUSTRY OR BUSINESS Human Rights in Ecuador
15. PLACE OF BIRTH Quito
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEGuHlermo Andrade
8. COUNTRY OF BIRT~Ujto
17. MOTHER
A. MAIDEN NAME Bertha Cifuentes
B. COUNTRY OF BIRT~uito
...
lB. NUMBER OF THIS MARRIAGE f
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE lAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) D DEATH
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 SPOUSE
22 SIGNATURE OF BRIDE ~
o 0 1ST
D 0 2ND
D 0 3RD
o 0 4TH
k owledge and belief that the information I provided is tr
o
o
D
23 SUBSCRIBED AND SWORN BEFOR
SIGNATURE OF TOWN OR IT DATE
This license authorizes the marriage in New York authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies W in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24 TOWN OR CI~Y CL~RK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glona J. ~ orse
TIME MONTH DAY YEAR MONTH
SEAL SIGNATURE ~ DATE'10/28/2002
'-v-I M~tr&1i~drJbush Rd. Falls NY 12590 03:33 AM 10
STREET STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
21 SIGNATURE OF GR
UJ
en
z
UJ
o
::::i
YEAR
29
200212
2002
'"';7
I!.. I
28. PLACE WHERE MARRIAGE OCCURRED
1 D CIVIL
o D RELIGIOUS
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
STREET
30. WITNESS TO CEREMONY
CITY/TOWN
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
A. STATE NEW YORK B COUNTY
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF D VillAGE OF
SPECIFY
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
