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COUN;,Qutchess
CITY TOWN Wappinger
~~~~~c;1368
~~~'~Jgrs5
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Norberto Hernandez
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
:l.(J-(]~
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Nicole A. Rowley
MIDDLE CURRENT SURNAME
~
A FULL NAME
11. A. FULL NAME
FIRST
FIRST
B BiRTH NAME. IF DIFFERENT
B BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C SURNAME AFTER MARRIAGE Hernandez
(OPTIONAL. SEE REVERSE\4 22 72 5932
o SOCIAL SECURITY NUMBER I - -
12. RESIDENCE ANew York BDutchess
ISTATE) ICOUNTY)
C CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
o STREET ADDRES~5 C Alpine Drive
ZIP 12590
o YES-o NO
1972
C SURNAME AFTER MARRIAGE
10PTIONAL . SEE REVERSEft83-58-8825
o SOCIAL SECURITY NUMBER U
2 RESIDENCE ANew York B. Dutchess
ISTATE) ..J--, (COUNTY)
C CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
~~~CIFY Wappinger
o STREET ADDRES~5 C Alpine Drive ZIP 12590
E is RESIDENCE WllHiN LIMITS OF CITY OR INCORPORATED VILLAGE' 0 YES"D NO
/10 /1968
DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE'
13 A. AGE30 13.B. DATE OF BIRTH 01 A4
MONTH DAY
3 A
AGE33
07
MONTH
3B DATE OF BI RTH
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATIO~dministrative Assistant
B. TYPE OF INDUSTRY OR BUSINESSSevem Trent Emtir. Ser"
15. PLACE OF BIRTrPeekskill, New York
(CITY. STATE/COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Construction
B TYPE OF INDUSTRY OR BUSINESsNortheastem Contractina
5 PLACE OF BIRn-COld S~rin~~ New York
(CITY. STA EICO RY IF NOT USA)
6. FATHER
A. NAME Hiainio Hernandez
B. COUNTRY OF BIRTHPuerto Rico
16. FATHER
A. NAMEWilliam Rowley
B COUNTRY OF BIRTiU S A
17. MOTHER
A. MAIDEN NAMECecelia I ester
8. COUNTRY OF BIRTilJ 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
7. MOTHER
A. MAIDEN NAME CRrmen VRlentine
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
o
(2) 0 DEATH
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' (31 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(31 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? r::J YES 0 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
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES :::: NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY. STATEICOUNTRY. IF NOT USA) SELF SPOUSE
D
o
z
o
~
~
g:
en
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to the
as to my right to enter into the marriage stale
21 SIGNATURE OF GROOM ~
1ST
2ND
3RD
c
22 SIGNATURE OF BRIDE ~
w
(/)
Z
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()
:J
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit n New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
[j 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) G_lo .
~-'" TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 05/1 0/2002
'"-v-I M2tiNK/i~d1Jbush Rd er Falls NY 12590 ""45 AM 05
STREET TOWN STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
YEAR
11
2002 07
09 2002
RELIGIOUS
1l"! CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUNT~Tt~
W
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et
()
u::
i=
a:
w
()
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF D TOWN OF ~VILLAGE ~~ Jl
~ECIFY ~,t,pf1,~~
NAME (PRINT)
SIGNATURE ~