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COUNT-Rutchess
CITYITOW~appinqer
~~~~kCR" 368
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Terrell L. Buttone
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
Ptllt
I II
V ,&..t7~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Doreen M. Rivera
~
11 A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
1 A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rivera - Buttone
(OPTIONAL. SEE REVERS~ 32 56-9618
D. SOCIAL SECURITY NUMBER' -
12. RESIDENCE New York BDutchess
(STATE) ..L (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN'"U VILLAGE
~~~cl~appinqers Falls
D. STREET ADORES4-0 North Gilmore Boulevard zlp12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ....0 YES 0 NO
21 1962
DAY YEAR
B BIRTH NAME, IF DIFFERENT
3. A. AGaO
01
MONTH
13. A. AG140
06
MONTH
13.B. DATE OF BIRTH
38. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATIONUnemploved
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRT5ronx. New York
(CITY. STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATIOrYideo Conference Coodinator
B. TYPE OF INDUSTRY OR BUSINEStI B Communications
15. PLACE OF BIRT5ronx New York
(CITY, sh TEiCOUNTRY IF NOT USA)
16. FATHER
A. NAMAnQelo Rivera
B. COUNTRY OF BIRM S A
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6. FATHER
A. NAMELarrv Buttone
B. COUNTRY OF BIRnU S A
7. MOTHER
A. MAIDEN NAME Annie Russ
B. COUNTRY OF BIRTHU S A
B. NUMBER OF THIS MARRIAGE 1
17. MOTHER
A. MAIDEN NAMEoIp.~nnip. Gu~rino
8. COUNTRY OF BIR1\J S A
lB. NUMBER OF THIS MARRIAGE 2
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? (3iD DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
c. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 05 /'16 /1996
MONTH DAY YEAR MONrw DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
1ST 0 0 1STn~/1fl/199fl S~nts Cnl7, Cslifomis tJ 0
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 knowle ge and belief that the mfDrmalion I prOVided IS true and that I de~lar that no legal Impediment eXists
as to my nght to enter Into the ma~ state. ~-
21 SIGNATURE OF GROOM ~ . 22 SIGNATURE OF BRIDf ~ .tt)\. Q C1 t l? ..A.....O\ ·
USE CU R NT NAME
23. ~~J,fT~~~D~N~O~~O;~ ~'?vBg~~i~E DATE 06/21/2002
This license authorizes the marriage in New York ate of the bride and groom named above by any person authorized by New York Domestic
Relations Law 911 to perform marriage ceremonies with n 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 or subsequent ceremony.
~ 24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)Gloria J
TIME
SEAL SIGNATURE DATJl6/27/2002
'-v-/ !~~r~me~ush RdJO\~~alls NY sT1T~590 ZIP 2:07 ~~
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 1 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED.
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
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:J
YEAR
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY t>\l\ck~~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF rl'VILLAGE OF
SPECIFY ~pin~ 'fa \I s
NAME (PRINT)
SIGNATURE ~