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Dutchess
COUNTY Wappinger
CITYiTO',:,'1l)
[)" [HICTt .:168
~~~I~~~R37
NUMBER
~ I A II: Ur- NI:VV YUNI\.
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM t!Jrc~'~s~~ndez
(THIS SPACE FOR STA TE USE ONL Y)
,,11)( t-j/.c:.f(
L 0 SUPPLEMENTAL FILE
FR~~s1~~~~W~ichelin
~
A FULL NAME
11 A. FULL NAME
FIRST
CURRENT SURNAME
CURRENT SURNAME
FIRST
MIDDLE
MIDDLE
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SE~er~'~~ Uutchess
2 RESIDENCE A (STATE) .,. B. (COUNTY)
C CHECK Of'i!i.. .D-~D' LLTm'J.f:J 0 VILLAGE
AND vvappulyers J!"a.l.lS
SPECIFY t 4 Markel Sheel Apt 8 t 259D
STREET ADDRESS Z$
E IS RE~~NCE WITHiN LIMITS OF CITY OR INCORPORATE~~LAGE' A 0 0 YES kh1%
3 A AGE .. 3B. DATE OF BIRTH L.:.. ~
MONTH DAY YEAR
BIRTH NAME (MAIDEN NAME), If ~FFE.RE~:r
Mlcnenn
C S~~~~~j",~E~~t~~C~~SEJlI7_72_1719
D. SOCIAL s~~wNf6l\ IJutcness
12. RESIDENCE A B.
(STATE) .;
C. ~~6CK 'fNappingEY 0 TOWN 0
SPECIFY 21 C~rr 011 Dr iy~
o STREET ADDRESS
(COUNTY)
VILLAGE
.;
YJ9'8lfO
YEAR
E IS RE~DfNCE WITHIN LIMITS OF CITY OR INCORPORAT"6~LLAGE' 73 0
13. A. AGE 13.8. DATE OF BIRTH C
MONTH DAY
4. EMPLOYMENT
14. EMPLOYMENT
Union House
B. TYPE OF IND~TRY OR BUSlNES~
uaxaca ue .JUarez, uaxaca
5. PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER JIM d
A. NAME oe en ez
B. COUNTRY OF BIRTH Oaxaca De Juarez, Oaxaca
Homemaker
A. USUAL OCCUPATION U b.
I lomema...er
B. TYPE OF IND4fTRY ~R BUSI~SS Y rk
15. PLACE OF BIRTH on ers, ew 0
(CITY, STATE.COUNTRY IF NOT USA)
16. FATHER K th M" h I"
enne IC e In
A. NAME 11 S A-
B COUNTRY OF BIRTH
17. MOTHER J M tt" "
A. MAIDEN NAME une a laCCIO
USA
8. COUNTRY OF BIRTH I
18. NUMBER OF THIS MARRIAGE
7. MOTHER EM P
A. MAIDEN NAME a erez
B COUNTRY OF BIRTH o~aca De Juarez, Oaxaca
8. NUMBER OF THIS MARRIAGE
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
OIVBRCE CIVIL A~ULMENT
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DljORCE CIVIL A~ULMENT
DltTH
D'{j TH
8. HOW DID LAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(21 0 DEATH
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 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
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 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
YEAR
15T 0 0 15T
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the infDrmatiDn I provided is tru
as to my right to enter into the marriage tate.
o 0
o 0
o 0
C I'
ediment exists
21 SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St te of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies withi New York State, THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is 0 be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CG1~LERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
DATE
by New York Domestic
~
{ SEAL }
'-v-I
TIME
MONTH
YEAR
04/16/2002
DATE
er Falls, NY 12590
AM 04
3:01 PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME ANO
PLACE INDICATED
STATE ZIP
27. TYPE OF CEREMONY .../
RELIGIOUS 1 ~IVIL
2B PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK B. COUNTY;];(;~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY OF 0 TOWN OF lJiAILLAGE O~ J,J
ECIFY 1AJ)ft'I'J ~!.M '1M'I8
OTHER, SPECIFY