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COUNT,Qutchess
CITYlTOwJI'lappinqer
~~~~~~., 368
~5~~JW122
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tom as FiQueiras
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE IJSE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nuri S. Cahill
~
I A. FULL NAME
11. A. FULL NAME
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFEREN~ejia
C. SURNAME AFTER MARRIAGE Mejia - Figueiras
(OPTIONAL. SEE REVERSEft60-82 8589
D. SOCIAL SECURITY NUMBER U -
12 RESIDENCE New York BDutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIF..wappinQer
D. STREET ADDRES~5 Orchard Drive
FIRST
CURRENT SURNAME
0-
N
B BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSito80-84-7660
o SOCIAL SECURITY NUMBER U
2 RESIDENCE ANew York B Dutchess
(STATE) J (COUNTY)
C CHECK ONE 0 CITV-D TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRES~5 Orchard Drive
ZIP12590
o YES"'D NO
18'63
YEAR
ZIP 12590
o YE~D NO
/1967
YEAR
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE38 13.B. DATE OF BIRTH 10 1J9
MONTH DAY
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGJ5 38. DATE OF BIRTH 05 /01
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATIONCarpenter
B. TYPE OF INDUSTRY OR BUSINESsSelf - Emoloved
5. PLACE OF BIRTiSpain
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATloJ3abvsitter
8. TYPE OF INDUSTRY OR BUSINESS
IS. PLACE OF BIRTtfleru
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Tomas Fiqueiras
8. COUNTRY OF BIRnSDain
7. MOTHER
A. MAIDEN NAME Fsperan78 Tobio
B. COUNTRY OF BIRTHSpain
8. NUMBER OF THIS MARRIAGE 1
16. FATHER
A. NAMEuqenio Meiia
8. COUNTRY OF BIRTli'eru
17. MOTHER
A. MAIDEN NAMERosa Narro
8. COUNTRY OF BIRTli1eru
18. NUMBER OF THIS MARRIAGE 2
a:
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3)6 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 06 /14 AOOO
MONTH DAY YEAR MON!lI DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? "[] YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 15T06114/2000 Queen, New York 0 "tJ
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 that the information I provided is true and that I declare th t no legal impediment exists
as to my right to enter into the marriage st~e. ' ~r
21. SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St e of
Relations Law 911 to perform marriage ceremonies withi ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
WOlf checked, this license is to be used only for the purpose of a second ocsubsequent.ce.remony.
en. ~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
ffi { } NAME (PRINT)Gloria
o ~ ~
:J SEAL SIGNATURE ~ DAT~8/07/2002
~ ~~~tcim~Hush Rd Wa Y 12590 ZIP 1 :38 ~~
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
by New YDrk Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON
MONTH I DAY I YEAR
2002 10
06 2002
28. PLACE WHERE MARRIAGE OCCURRED
1 p(.CIVIL
A. STATE NEW YORK 8. COUNTY VJ7Cif€5S
RELIGIOUS
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~()cJ..H-~EEf"&' I E
,..... =#2fJ (
T1TLE~te~ -r;W/lJ UU~ fia
/J, DATE ~Sf ;;2'-( ;)6,,?-
, j!h-Pr'/t:N(J-G,Q~ f774J.~ ~ /~f}.(j
STREET CITYITOWN STATE'
30. WITNESS TO CEREMONY) I 31.
NAME (PRINT) . I1ErF'.
29. OFFICIANT
NAME (PRINT)
SIGNATURE