140
This license authorizes the arriage in New York S te of t and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies withi New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is 0 be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CL.ERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } .NAME (PRINT) Glon J. M~rse TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ - UA1E09/04/2002
MAI~~~QI)W:s"s 0:51 AM 09
"-v-I LU MIOOleDush Rd in er Falls NY 12590 PM 05 2002 11 03 2002
STREET CITYITOWN TATE ZIP
~~~R~~~Ri~~~ lo~O'r~~Nif:~ 26. SOLEMNIZATION OCCURRED 27. TY..'? OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 V'f!ELlGIOUS 1 D CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 D OTHER, SPECIFY
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John E. Hernandez
MIDDLE CURRENT SURNAME
COUNTyDutchess
CITYfTOWN Wappinger
~~J~~CRT1368
~5~I~J~R140
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEft65-68-1881
D. SOCIAL SECURITY NUMBER U
2 RESIDENCE A. New York B Ulster
(STATE) (COUNTY)
C. CHECK ONE D CITY -tJ TOWN D VILLAGE
~~~CIFY Hiqhland
D. STREET ADDRESS 12 Bell Drive ZIP 12528
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES"tJ NO
1 n An /1917
MONTH DAY YEAR
3. A. AGr:29
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Delivery Driver
B. TYPE OF INDUSTRY OR BUSINEssDutchess Dodge
5. PLACE OF BIRT~ronx. New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Juan Hernandez
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME Dolores Perez
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (srD DIVORCE (S) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? 11 / 12 /1997
MON~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 1] YES D 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 11/12/1997 Tamoa, Florida
DEATH
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::::i
I STATE FILE NUMBER I
(THIS SPACE FOR STA TE USE ONL Y)
q,;~ -tJ~
Lo SUPPLEMENTAL FILE -1
11. A. FULL NAME
FROM THE BRIDE
Kristianne E Klan
MIDDLE COf'IRENT SURNAME
FIRST
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hernandez
(OPTIONAL. SEE REVERSE)086-66-5707
D. SOCIAL SECURITY NUMBER _________
12. RESIDENCE ANew York B. Ulster
(SrA~) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~ClFyHighland
D. STREET ADDRESS 12 Bell Drive ZIP 12528
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES tj NO
13. A. AGE7? 13.B. DATE OF BIRTH 02 An t919
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATIONWaitress I Manager Assistant
B. TYPE OF INDUSTRY OR BUSINESsBuaaboo Creek
15. PLACE OF BIRTHBrewster. New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMEWilliam KIa; Jr.
B. COUNTRY OF BIRTIU S A
17. MOTHER
A. MAIDEN NAME I inda Phillip!;
B. COUNTRY OF BIRT.tJ S A
1 B. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (S) 0 DIVORCE (3) D ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
D 1ST
D 2ND
D 3RD
D 4TH
lef t at the information I provided is true
D D
D D
D D
D D
pediment exists
2. SIGNATURE OF BRIDE ~
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT::!2f.,(1(Jf,;sS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF ~AGE OF
SPECIFY W;:;fflrl~,es f/;u..S
NAME (PRINT)
SIGNATURE ~