119
]
a.
N
:t-:
~.:>'
..-
,....
0
>-
iD
Clt
L-
iD
-,
~ W
f-
"
i,I) f-
<Jl
Z
.l&
L-
J
~
w
'" -
15
I
~
~
uJ-
~
~
~
~
LL
.~iio
~
w
'"
W
I
~
(f)
(f)
W
'"
o
o
"
>-
LL
i3
w
a.
(f)
Z:i:z
"'>-0
~~t=
~~~
>-WZ
(f)..J::;
:JOW
~"'O
>-Z(f)
Z-
G~~
[aU)
0>->-
UjtMC3
b~~
Z::i~
COl;iH~utchess
CITYfTOWNWappinqer
~~~:~CR'1368
~5~I~J~R119
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Gustavo Romero
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
t
~~,1.CI 'Nt
I
~Irl
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Herlinda Segarra
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Segarra
(OPTIONAL. SEE REVERSEJo 39-8"3775
D. SOCIAL SECURITY NUMBER I U-
12. RESIDENCE,New York BOut chess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY "6 TOWN 0 VILLAGE
~~~clrWappinqer
o STREET ADDRES9 Phvllis Drive
ZIP12590
o YES"'D NO
v.11R
YEAR
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERS5i 44-02 7984
o SOCIAL SECURITY NUMBER I -
2 RESIDENCE ANew Jersev B. Essex
(S~TE) (COUNTY)
C CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY Newark
D STREET ADDRESS~? Manchester Place Apt. Z1P07104
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? "0 YES 0 NO
Al1 /\911
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AG~4 13.B. DATE OF BIRTH n1 )(1
MONTH DAY
3 A. AGr25
02
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATIO~.uditor
8. TYPE OF INDUSTRY OR BUSINEs::Marsh & Me lennan Co.
15. PLACE OF BIRTtSeacaucus, New Jersery
(CITY, ST ATE/COUNTRY IF NOT USA)
16. FATHER
A. NAMWictor Segarra
B. COUNTRY OF BIRTftcuador
17. MOTHER
A. MAIDEN NAM~Argnth AArr.n
8. COUNTRY OF BIRrftcuador
18. NUMBER OF THIS MARRIAGE 1
38. DATE OF BIRTH
t-
:>
<(
c
w-
"u..
:5u..
~<(
Z
;:
o
t:
>-
f-
6
4. EMPLOYMENT
A. USUAL OCCUPATION Truck Driver
B. TYPE OF INDUSTRY OR BUSINES~iehmond ExDress
5. PLACE OF BIRTtfcuador
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAMESequndo Romero
8. COUNTRY OF BIRnEcuador
7. MOTHER
A. MAIDEN NAME Maria Silva
8. COUNTRY OF BIRTH Ecuador
8. NUMBER OF THIS MARRIAGE2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
~
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C DATE LAST MARRIAGE ENDED? 08 /13 /2001
MONJII DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? TI YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20.
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
15T08/13/2001 state Of New York 0 "tJ 15T
o 0 2ND
o 0 3RD
o 0 4TH
st of my knowledge and belief that the information I provided is true and that I declare that no leg
<
DEATH
o
DEATH
o
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
YEAR
C, DATE LAST MARRIAGE ENDED?
MONTH DAY
D, ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
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
o 0
o 0
o 0
o 0
'mpediment exists
it
'"
::;
::J
Z
o
Z
"
f-
W
W
0:
f-
<Jl
by New York Domestic
22. SIGNATURE OF BRIDE ~
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO
SIGNATURE OF TOWN OR CIT
w
en
z
w
()
::::i
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 to perform marriage ceremonies W 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 orsubsequenl"ceremony.. .
~ 24 TOWN OR CITY CLERK 25 A SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)G_lori Mo se . .
TIME ~AA
SEAL SIGNATURE ~ DATJ)8/02l2002
~ !:~r~m~ljUSh Rd inCITY~!:alls NYST1T~590 ZIP 2:41 ~~
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 0 RELIGIOUS
~t:~E ~~gl:T~~E TIME AND ! :L.
01 2002
MONTH
YEAR
2002 10
28. PLACE WHERE MARRIAGE OCCURRED
~IVIL
A. STATE NEW YORK B. COUNT~; ~~et6
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
'\
o CITY OF .)(TOWN OF 0 VILLAGE OF
SPECIFY \-J.. >0. pp' r1...1e (
f. Wf}L-/vF0
~U: .
29. OFFICIANT
NAME (PRINT)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) i- ~;J-
SIGNATURE ~ ...