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COUNTY L..,.of~H,VII'-v.,;:)
CITY/TOWN Wappinger
DIST'llCT 1368
NIMBER
~5~I~J~R 77
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Des; Medina, Jr.
MIDDLE CURRENT SURNAME
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Barbara V. Goebel
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A FULL NAME
11. A. FULL NAME
FIRST
FIRST
MIDDLE
CURRENT SURNAME
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B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE Medina
(OPTIONAL - SEE REVERSE) 091 64 8734
o SOCIAL SECURITY NUMBER --
12. RESIDENCE A. N Y Dutchess
(STATE) ~ (COUNTY)
C. CHECK ONE 0 CITY UTTOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 689 Dutchess Turnpike ZIP 12603
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 073-68-2403
o SOCIAL SECURITY NUMBER
2 RESIDENCE A. N Y B. Dutchess
C CHECK ONE (STA~E) CITY d TOWN 0 VILLAGE (COUNTY)
~~~CIFY Poughkeepsie
o STREET ADDRESS 689 Dutchess Turnpike
12603
ZIP
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' 0 YES d NO E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' 0 YES d NO
3 A. AGE 21 3BDATEOFBIRTH 06 / 21 / 198 13A. AGE 21 13BDATEOFBIRTH 07 /19 /1980
MONTH DAY YEAR MONTH DAY YEAR
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS Burger King
15. PLACE OF BIRTH Beacon, New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME William Goebel, Jr.
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Barbara Istvan
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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A. USUAL OCCUPATION Detailing
B TYPE OF INDUSTRY OR BUSINESS Poughkeepsie Ford
5. PLACE OF BIRTH Bronx, New York
(CITY. ST A TE!COUNTRY IF NOT USA)
6. FATHER
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A. NAME Desiderio Medina
B. COUNTRY OF BIRTH Puerto Rico
7 MOTHER
A. MAIDEN NAME Hilda E. SantiaQo
B. COUNTRY OF BIRTH Puerto Rico
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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B HOW DID LAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END' (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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DATE 06/07/2002
by New York Domestic
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
wi edge and belief that the information I provided is true and that I decl
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21 SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
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23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law !i11 to perform marriage ceremonies within 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 CLE~K 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) GlOri
TIME
MONTH
~
{ SEAL }
'-y-I
ZIP
AM
01:1&M
06
l' CIVIL
28. PLACE WHERE MARRIAGE. OCCURR~ ~ .
A STATE NEW YORK B COUNT~ I GUc
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /-
o CITY OF 0 TOWN OF eVVlLLAGE OF
SPECIFY fA) Mp rrVb1~ ?;4ib
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SIGNATURE ~
MAIL; ;00
STREET
30 WITNESS TO CERE
NAME (PRINT) '~l '
SIGNATURE ~ W
DOH-98 (11/98)