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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Leonardo Raul Naveda
C SURNAME AFTER MARRIAGE
(OPTIONAL SEE REVERSE)
D SOCIAL SECURITY NUMBER
2 RESIDENCE ,New York
C CHECK ONE (STA~) CITY 0 TOWrlf"D
~~~CIFyWappinqers Falls
STREETADDRES~3 South Remsen Avenue zIP12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ....u YES 0 NO
All /1910
DAY YEAR
COUNT putchess
CITYTO,~~aDDinqer
~~~~~ca 368
~5~i~~~' 20
A FULL NAME
FIRST
"-
N
BIRTH NAME. IF DIFFERENT
3 A
A~1
3B. DATE OF BIRTH
STATE FILE NUMBER
.J I!_ ,1r!SJlACE FOR STATE USE ONL Y)
/jrMCi/1.kt N f. Ve- f( tL 5 [J}
/1C!7_1.1:J CI O/-II/ft,EJ /';(/--rJ3
~ I Jcfr/1! n-t nl?~t.~(tR.
L n SUPPLEMENTAL FILE 9t~ 1f tf ~
I
MIDDLE
CURRENT SURNAME
FROM THE BRIDE
Aida C. Elsayed
FIRST MIDDLE CURRENT SURNAME
BIRTH NAME (MAIDEN NAME). IF DIFFERENRomero
C SURNAME AFTER MARRIAGENaveda
(OPTIONAL. SEE REVERS5oI00-80 1408
o SOCIAL SECURITY NUMBER' -
12. RESIDENCE New York Dutchess
c. CHECK ONE (STA~f) CITY 0 TOWN""b VILLAGE (COUNTY)
~~~cIFWappinqers Fans
D. STREET ADDRES13 South Remsen Avenue
11 A FULL NAME
BOut chess
(COUNTY)
VILLAGE
09
MONTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13 A. AGd-1 13.B. DATE OF BIRTH 03 .8'1
MONTH
ZI~ 2590
o YE~'b NO
1.9'61
YEAR
DAY
14. EMPLOYMENT
A. USUAL OCCUPATIOflorist
B. TYPE OF INDUSTRY OR BUSINESSelf - Employed
15. PLACE OF BIRTfcuador
(CITY. STATE/COUNTRY IF NOT USA)
4 EMPLOYMENT
A. USUAL OCCUPATlorConstruction
B TYPE OF INDUSTRY OR BUSINESNew York Corporation
5 PLACE OF BIRl-Araentina
~ITY. STATE/COUNTRY IF NOT USA)
6 FATHER
A. NAMEPeter Naveda
B COUNTRY OF BIRTiArgentina
7 MOTHER
A MAIDEN NAME l.armp.n Figp.roa
8. COUNTRY OF BIRn-Argentina
8 NUMBER OF THIS MARRIAGE1
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 (311] ANNULMENT' (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3j"'D DIVORCE (310 ANNULMENT (2) 0 DEATH
/ / C DATE LAST MARRIAGE ENDED? 03 /27 /1998
MONTH DAY YEAR MOt{[.lil DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES U NO D ARE ANY FORMER SPOUSE(S) ALIVE? LJ 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
o 0 1s,fl?f21f199? Queens, New York [] '~'b
o 0 2ND [J [J
o 0 3RD [J
~ D 4TH D II
nO~"17_e_and belief that the information 1 provided is true~and thatl,.dJec:~e;~~:t~: ~e~ga~ ~mp. e~dimen:/eXists
22. SIGNATURE OF BRIDE ~ ;.' ~ (A/<' Y ':fL
USE CURRENT NAME ..
23 SU'BSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 08/05/2 02
This license authorizes the marria e St te of the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies withi ew 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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT I ri
TIME YEAR MONTH
SEAL.' . .SI.tNAT~E ~ DATdl8/05/2002
~'2l'iO'Midd~~USh Rd Wa Y 12590
- STREET ".', STATE
~ ~~\:~Ri~~~ IO~O~~~N~EE~ 26" SOLEMNIZATION Oq"C RED 27 TYPE OF CEREMONY
S~ NAMi9B'.ABOVE ON THE TIME MO DAY YEAR 0 D RELIGIOUS 1 D CIVIL
QAlE AND fiT T\IE TIME AND AM
PLACE IND~CtTEO' " l ; PM 9 0 OTHER, SPECIFY
16. FATHER
A. NAMfroUan Romero
B. COUNTRY OF BIR-iicuador
17. MOTHER
A. MAIDEN NAMCarmp.n Pae?
B. COUNTRY OF BIR-ficuador
18. NUMBER OF THIS MARRIAGE 2
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
C DATE LAST MARRIAGE ENDED?
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to th .
as to my right to enter into the marriage state. /
21 SIGNATURE OF GROOM ~ . /
2~:PFFIC'~T'" "";' 1 ,\,'
NAME (PM;ll'~.'- .' ';'.~.:~>:, .~
SIGr--tATl,IRE ~ "., ~t. .
MAILtN15~.~ORESS. ' ,--": -.
C r- ..,
;. ,"")
STREET _. ",
30. WITNESS TO CEREMONY
CITY/TOWN
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
DEATH
o
DEATH
o
ZIP
YEAR
04 2002
28 PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B. COUNTY
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
TITLE
o CITY OF 0 TOWN OF 0 VILLAGE OF
DATE
SPECIFY
STATE
ZIP
31 WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~