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COUNT,Qutchess
CITYfTOWN Wappinger
~~~~kCR1368
~5~I~WS 7
::s I A I t:. Ur- Nt:. VV Y UNt\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ruben M. Rodriquez
MIDDLE CURRENT SURNAME
FIRST
(THIS SPACE FOR STA TE USE ONL Y)
t!Jtrt 5- 15. t'~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica Rodriquez
MIDDLE CURRENT SURNAME
~
A FULL NAME
11. A. FULL NAME
FIRST
B BIRTH NAME. IF DIFFERENT
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Rodriquez
(OPTIONAL - SEE REVERSEn88-58-') 120
o SOCIAL SECURITY NUMBER U .J
12 RESIDENCE ,.New York BDutchess
(STATEI (COUNTY)
C CHECK ONE 0 CITY "!"J TOWN D VILLAGE
~~~cIF,Beekm an
o STREET ADDRESl Pine Street
ZIP12570
D YES....D NO
1-9"75
YEAR
C SURNAME AFTER MAP,RIAGE
(OPTIONAL - SEE REVERSiJ1'I57 79-0116
o SOCIAL SECURITY NUMBER :1 -
2 RESIDENCE ANew York B Dutchess
(STATE) ~ (COUNTY)
C CHECK ONE D CITY C TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDREss6509 Princess Circle ZIP 12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? D YES.,I'D NO
/12 /1971
DAY YEAR
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13 A, AGr2.7 13.B. DATE OF BIRTH 04 112
MONTH DAY
3 A
AGE31
03
MONTH
14. EMPLOYMENT
A USUAL OCCUPATIO~ental Assistant / Receptionist
B TYPE OF INDUSTRY OR BUSINESl4id - Hudson Dental
15. PLACE OF BIRT~anhattan
(CITY, STATE..COUNTRY IF NOT USA)
16, FATHER
A NAMERichard Rodriquez
B, COUNTRY OF BIRTIJ S A
17, MOTHER
A MAIDEN NAMEFvelyn Va7quez
B. COUNTRY OF BIRTIJ S A
1 B. NUMBER OF THIS MARRIAGE 1
19, PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
3B. DATE OF BIRTH
4 EMPLOYMENT
A USUAL OCCUPATION Night Manager
B TYPE OF INDUSTRY OR BUSINESsQunkin Donuts
5 PLACE OF BIRTMexico City
(CITY, STATE COUNTRY IF NOT USA)
6. FATHER
A NAME Ezequiel Rodriguez
B. COUNTRY OF BIRT~exico
7. MOTHER
A. MAIDEN NAME Maria Magdalena Munoz
B COUNTRY OF BIRTH Mexico
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END' (3) [j DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B, HOW DID LAST MARRIAGE END? (3)::J DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) CJ DEATH
MONTH DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES [j NO
20 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
MONTH DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? eYES D NO
10 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
c
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a:
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15T D 0 15T
2ND 0 0 2ND
3RD D [J 3RD
~ 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
as to my right to enter into the rriage state,
21 SIGNATURE OF GROOM ~ ~e ~
L...-..;
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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
Relations Law 911 to perform marriage ceremonies wit New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY
D 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) Glo . M
~-' TIME YEAR
SEAL SIGNATURE ~ DATJJ5/10/2002
~ ~~I~ta~~~ush Rd er Falls NY 12590
STREET C TOWN STATE
~~~R~~~Ri~~~ 10~0~~~N~ZEE~ 26 SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ./
SONS NAMED ABOVE ON THE TIME MO DAY YEAR 0 D RELIGIOUS 1 ~CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED
09 2002
MONTH
YEAR
2002 07
ZIP
28 PLACE WHERE MAP,RIAGE OCCURRED
A STATE NEW YORK B COUNT,J( u121k'!
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /'
[J CITY OF ::J TOWN OF ~ILLAGE OF "'. )J
SPECIFY 1A)~/1V6~ ~
9 0 OTHER, SPECIFY
29 OFFICiANT
NAME (PRINT)