171
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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)
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DISTRICij S68
NUMBER
REGISTERl 71
NUMBER
Il/AVt /('41JIA
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Branka HerGeg
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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
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B BIRTH NAME, IF DIFFERENT
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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)
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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
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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
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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
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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 ~
