170
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY 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 onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
IOI'}::ath::an"'4 \/al'} ~ 'l~
MIDDLE R SURNAME
COUNlY Dutchess
ClTYfTOWN Wappinger
~lJJ:~W 1368
~5~~J~R 170
1. A. FUll NAME
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEh
D. SOCIAL SECURITY NUMBER 7!:l-R6-7016
2. RESIDENCE A. N ~ATE) B. D~sc::
C. CHECK ONE 0 CITY -tJ TOWN 0 VILLAGE
AND W .
SPECIFY app'ngp-r
D. STREET ADDRESS 508 Chp-If:;p-a Cay ZIP 1 ?500
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILlAGE? 0 YESo,l] NO
3. A. AGE28 3B. DATE OF BIRTH ~ / t~ / W-4
4. EMPLOYMENT
A. USUAL OCCUPATION ~llrlj:ll'}t
B. TYPE OF INDUSTRY OR BUSINESS ~ II N V Np.w P::alt7
5. PLACE OF BIRTHPQMq~l~F Jt~ Vork
6. FATHER
A. NAME .lnhn V::an AI IrAn
B. COUNTRY OF BIRTH Englanrl
7. MOTHER
A. MAIDEN NAME Paulette Kujda
B. COUNTRY OF BIRTH I' ~ A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o n
DEATH
n
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
1ST
2ND
3RD
4TH
I, being duly SWDm, depose a
as to my right to enter into the
21. SIGNATURE OF GROOM"
o
o
o
~
{ SEAL }
'-v-'
STRE
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
A
27. TY~F CEREMONY
o Iel"'RELlGIOUS
9 0 OTHER, SPECIFY
NAME (PRINT)
SIGNATURE ~
DOH-98 (11198)
~'",I" rl~ ''''''IIID..n
(THIS SPACE FOR STATE USE ONLY)
~}zt /!-7-04
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mar~JeD. Espin~NTSURNAME
-.J
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~JN~~:~~~~~SWm Sur.en
D. SOCIAL SECURITY NUMBER 058-74 8773
12. RESIDENCE A.N V B. Dllt",hc.sS
'(STATE) ~
C. CHECK ONE 0 CITY Iil! TOWN 0 VILLAGE
AND W. .
SPECIFY. apprnger
D. STREET ADDRESs?7 ~eagi,? QrivE' ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE26 13.B. DATE OF BIRTH ~H / ~Y 1~1i
14. EMPLOYMENT
A. USUAL OCCUPATION T ecf:1nician
B. TYPE OF INDUSTRY OR BUSINESS' B M Corp
15. PLACE OF BIRTHNI!IlY~Bu~WN~1?li
16. FATHER
A. NAME()s~ar E$piooza
B. COUNTRY OF BIRnf?en I
17. MOTHER
A. MAIDEN NAME Ana Cu~.'a
B. COUNTRY OF BIRnEcuador
18. NUMBER OF THIS MARRIAGE 1
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) 0 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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o 0
o 0
o 0
o 0
egal impediment exists
.
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
1 :59 AM
PM 10
22
2002 12
20 2002
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~17:IIr?:i s
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) .
o CITY OF 0 TOWN OF ~GE OF
SPECIFY W 11I'l~S" ffta s
NAME (PRINT)
SIGNATURE ~