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171 - STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM Fredy Monroy MIDDLE CURRENT SURNAME I STATE FILE NUMBER (THIS SPACE FOR STA TE USE ONL Y) "I COli NT-R ll1 chess 'clTYrrowlvappmger DISTRICij S68 NUMBER REGISTERl 71 NUMBER Il/AVt /('41JIA L 0 SUPPLEMENTAL FILE FROM THE BRIDE Branka HerGeg ~ 1. A FULL NAME 11. A. FULL NAME FIRST MIDDLE CURRENT SURNAME FIRST 3 A. AG~9 3B. DATE OF BIRTH .n YES 0 NO ,/1972 YEAR B. BIRTH NAME IMAIDEN NAME), IF DIFFERENT C. SURNAME AFTER MARRIAGE Monroy (OPTIONAL - SEE REVERSEU'.'1_'''''_'''ofj;) D. SOCIAL SECURITY NUMBER U UU U 12. RESIDENCE ANew York BDutchem, (STATE) .,. (COUNTY) C. CHECK O~e, 1] CITY Cl. TQWN 0 VILLAGE AND wapplngers ram: SPECIFY 6506 Princess Circle 12590 D. STREET ADDRESS ~ E. IS RESI~ENCE WITHIN LIMITS OF CITY OR INCORPORATED ~ILLAGE? ~ 0 Y~S 9 NO 13. A. AG~i:l 13.B. DATE OF BIRTH O~ ;cl .J>> 4 MONTH DAY YEAR "- N B BIRTH NAME, IF DIFFERENT 1';:) ~ ('.~ ..- .:...:. '- p r ~ Q) UJ Z :;: .... (J) C SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERS'3r."r.. 04 .. fl''; l: D SOCIAL SECURITY NUMBER Ur../-u"t- I 'J"') 2 RESIDENCE ANew York B Dutchess (STATE) '" (COUNTY) C X~6CK O~~ , 0 CITY r, Q.. Tqym 0 VILLAGE SPECIFY wappinger" railS fj~)Ub I-'nnCeS5 Circle D. STREET ADDRESS MONTH 14. EMPLOYMENT p"...."" .,.+i....,.., fI "''''....,.i'''+e A. USUAL OCCUPATION ยท "'.......0'. VII,...."'~V.. ..n I. B. Ivl. B. TYPE OF IND'6TR.Y ~ i;lIJSINE~S 15. PLACE OF BIRTH slJe cma la (CITY. STATE/COUNTRY IF NOT USA) 4. EMPLOYMENT A. USUAL OCCUPATION Maintenance B. TYPE OF INDUSTRY OR BUSINESS,mpenal Garaens 5. PLACE OF BIRTHQuezal Tepeclue ChlqUltnula (CITY, STATE/COUNTRY IF NOT USA) - Ul m I..L. 1! .... ~J :> u;- <( ~a. c ~~ u: ~jLL. ~- ~ <( ?a; ~ ffi ;: "'- t: ~3 u ~111 ~ =1.) H:: :c u. J ~ Ir. ~ ) ! ! 6. FATHER A. NAME Telmo Monroy 8. COUNTRY OF BIRTHGuatemala 16. FATHER A. NAMJ3ranko Herceg 8. COUNTRY OF BIRTs..,-oana 17. MOTHER L. k ""'I d - A. MAIDEN NAME }u....a \,j.a Ole B. COUNTRY OF BIRT~roa~;a lB. NUMBER OF THIS MARRIAGE 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DjlJORCE CIVIL AI)ItJULMENT U U D~TH U 7. MOTHER c;:"'tu'T'ina Pere"" A. MAIDEN NAME ~'U Jill' L. 8. COUNTRY OF BIRTH Guatemala B. NUMBER OF THIS MARRIAGE 1 9. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVBRCE CIVIL A~ULMENT 0'0' TH B. HOW DID LAST MARRIAGE END? 131 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (3) 0 ANNULMENT / / (2) 0 DEATH 8. 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 ANNULED, PROVIDE THE FOLLOWING INFORMATION DATE OF DECREE PLACE ISSUED AGAINST WHOM (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE 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 w en z w (,) ::; 1 ST 0 0 1 ST 0 0 2ND 0 0 2ND 0 0 3RD 0 0 3RD 0 0 4TH 0 0 4TH 0 0 I, being duly sworn, depose and say, that to the best of my knowledge and belief 1hat the Information I provided is true and that I declare that no legal impediment exists as to my right to enter into the arr" ge state. n .,:l _ ,...ff, 21. SIGNATURE OF GROOM ~ ~ 22. SIGNATURE OF BRIDE ~ .J;#a~ ~~ 23. SUBSCRIBED AND SWORN TO BEFORE ME USE CURRENT NAME 191/23/2002 SIGNATURE OF TOWN OR CITY CLERK ~ DATE 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 . hin 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. ~ 24. TOWN OR CITY CL~RK 25. A. SOLEMNIZATION PERIOD BEGINS } ""' I""" Glona J. M~rse ""' "0"'" {SEAL SIGNATURE ~ -- ~ ~~TE 10/23/2002 '-y-I M~rrrM(jf~bush Rd, .,-.ppin er falls, NY 12590 i2Zi AM 10 STREET CITYfTOWN STATE ZIP - ~ PM I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY THE MARRIAGE OF THE PER. _/ SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 l!r RELIGIOUS DATE AND AT THE TIME AND AM PLACE INDICATED l: 30 (I l S 0'2 90 OTHER, SPECIFY 29 OFFICIANT j{) ( , ( (1) ~. NAME (PRINT) be., l' ". IV eft... I. j SIGNATURE ~ _~ r;; I _ .' MAILING ADORE II (AI,. f~t, {r~r L1Jetl'fJ'~t!.YS fcellt; STREET CITyrrOWN ' "7" 30 WITNESS TO IlCER MONY N f..,( 0 S ru L {C NAME (PRINT) ~ {~,,-. v ~;9 , SIGNATURE ~ :.u-z,..... Ll~ DOH.98 (11/9B) YEAR c: UJ "' ::;; ::> z Cl z <( .... UJ UJ c: .... (J) 10 CIVIL 2B. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNTYPo.t. fc;~ c. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF 0 TOWN OF ~LLAGE OF :i:;i ~~ w x:~ t- ffiz <( d~ (.) ~5l u: 5 u. ....- ~o a: ~~ w ~ C3 (,) 15"' u ~~ TITLE ~fLo t." Pr/~f DATE 11/2.3/02- I AJy STATE' 125'rto SPECIFY W4f.r'.,Jers kr/S 31. NAME (PRINT) SIGNATURE ~