047
]
a.
0:;
0
m
~I
N
T"""
..:.:
'-
5!-
5: cD
;"
Q) if>
Z
III
m
,U". I-
~ :;
uo:..;
~ <t
~J C
;:c w u::
~ CJ
j LL
~ '> <t
z
'"
0
a: r-
&i i:
u
~
'Iii
~
4:
~
UJ
eN
:r-.l
I
"
)
ffi
al
:'
:0
Z
:0
Z
<{
CD
W
((
Vi
z
0 W
i=
< ....
N <t
z
ai U
0 u:
(f) t=
6 a:
(f) w
>-
< U
0
~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Benjamin Pedroza
MIDDLE CURRENT SURNAME
o [J 1 ST L,
[] [J 2ND C
o [J 3RD C
u [] 4TH C
Y knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNA TURE 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 by New York Domestic
Relations Law Sll to perform marriage ceremonies within 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 C~ERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glona J
{TIME MONTH YEAR MONTH DAY
SEAL SIGNATURE" DATE04/30/2002
'-v-I ~b'~fa~i:r6ush Rd Wa ails NY 12590 2:45 ~~ 05 01 200206 29 2002
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DA TE AND AT THE TIME AND
PLACE INDICATED
COUNTPutchess
CITY TOWNWappinger
DISTRIC:1368
NUMBER
~5~'~~~F4 7
A FULL NAME
FIRST
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
10PTIONAL . SEE REVERSS 14-78-3510
D SOCIAL SECURITY NUMBER
2 RESIDENCE ANew York s Dutchess
ISTATEI ~ ICOUNTY)
C CHECK ONE Q CITY [J TOWN [] VILLAGE
~~~CIFY Wapplngers Falls
o STREET ADDRES~2 Spnng Street
ZIP 12590
~
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE' eYES [] NO
/15 /1970
3 A
AG~1
08
3B. DATE OF BIRTH
MONTH
DAY
YEAR
4 EMPLOYMENT
A. USUAL OCCUPATIONlnventory Specialist
B. TYPE OF INDUSTRY OR BUSINES~est Buy
5 PLACE OF BIRT~OS Angeles, California
(CITY, STATE COUNTRY IF NOT USA)
6. FATHER
A. NAME Carlos Pedroza
B. COUNTRY OF BIRTHU S A
7. MOTHER
A MAIDEN NAME Edith Rios
B COUNTRY OF BIRTH Puerto Rico
NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8 HOW DID LAST MARRIAGE END? (3) [J DIVORCE
C DATE LAST MARRIAGE ENDED?
(21 [J DEATH
(3) D ANNULMENT
/ /
MONTH DA Y YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? [] YES [] 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
1ST
2ND
21 SIGNATURE OF GROOM ~
w
(J)
z
w
U
...J
o D RELIGIOUS
9 D OTHER. SPECIFY
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
a/1it,
S -7 '()~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Katherine E. Donnelly
~
11 A. FULL NAME
FIRST
CURRENT SURNAME
MIDDLE
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Pedroza
(OPTIONAL. SEE REVERSE077 70-8988
o SOCIAL SECURITY NUMBER -
12 RESIDENCE /Jew York B Dutchess
C CHECK ONE (STAg) CITY [J TOWN '6 VILLAGE (COUNTY,
~~~CIFyWappingers Falls
D STREET ADDRES~2 Spring Street
ZIP12590
~L: YES 0 NO
1.878
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13 A. AG~4 13.8. DATE OF BIRTH 01 ;f8
MONTH
DAY
YEAR
14. EMPLOYMENT
A. USUAL OCCUPATIONChef
8 TYPE OF INDUSTRY OR BUSINESJI Continori
15. PLACE OF BIRT~old Spring, New York
(CITY, STATE'COUNTRY IF NOT USAj
16. FATHER
A. NAMJ<enneth Donnelly
B COUNTRY OF 8IRT4I S A
17 MOTHER
A. MAIDEN NAMEPaulette De Gelormo
B. COUNTRY OF 8IRT~ S A
1 S. NUMBER OF THIS MARRIAGE 1
19 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED 8Y
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
8 HOW DID LAST MARRIAGE END? (3) [J DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) [] ANNULMENT
/ /
121 [J DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? eYES [] NO
20 IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DA TE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY. YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
22. SIGNATURE OF 8RIDE ~
25 B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT ON
YEAR
17-CIVIL
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8 COUNTY DUiC ttESs
TITLE~&,1 rdC/fA..ilir,a-#:z.cr (
~2-
A(1
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
[] CITY OF [] TOWN OF K VILLAGE OF
SPECIFY f'),:-f{J1 rJ~ Fltu.--s
29 OFFICIANT
NAME (PRINT)
E..L.
STATE
31
NAME (PRINT)
SIGNATURE ~