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Dutchess
COUNTY 0
Wl:Ipplnger
CITY/TOW'"
DISTRICTI...68
~~~I~~~R33
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROO~
Chnstopher R. Pacheco
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
;Qjr;[
6 -1 ' t'~
L 0 SUPPLEMENTAL FILE
FROM TLHE 88/QJ:
Isa M. Kyan
-.J
A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
fUR RENT SURNAME
"'-
N
B BIRTH NAME. IF DIFFERENT
B BIRTH NAME (MAIDEN NAME) ~~6~e~0
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)'I 'I 7-68-4428
o SOCIAL Sf,C~eRlwTY ~~OBEfL
N T I rK Outcness
12. RESIDENCE A. (STATE) " B (COUNTY)
C. ~~6CK ~oug~EfJlPSIe TOWN 0 VILLAGE
SPECIFY 422 5uulh ROl:ld Apl. H 12
o STREET ADDRESS
C s~~~~~NtLTE~~t~~C~~sE(}60-58-3592
o SOCIAL SEr;rG~t'H~ uutcness
2 RESIDENCE A. (STATE).1 B. (COUNTY)
C ~~6CK 013ougHk~~tp~eOWN 0 VILLAGE
SPECIFY 422 Suulh Ruad A l. H 12
D. STREET ADDRESS P
12601
ZIP
.;
E is R~ffNCE WITHiN LIMITS OF CITY OR INCORPORATEij'tLAGE? e30 YES );h~
3 A. AGE 3B. DATE OF BIRTH /" ~
MONTH DAY YEAR
"
E is RE~~NCE WITHIN LIMITS OF CITY OR INCORPORATmLLAGE?). 6 0 Y1&tiO
13. A. AGE 13.8. DATE OF BIRTH _ E
MONTH DAY YEAR
14. EMPLOYMENT A 0 t t St M
5515 an ore anager
A. USUAL OCCUPATION D r10 t - t r I
DU Ing un I_oa raC ory
B. TYPE OF IND'RTRY O~ BUSI~S rk
15. PLACE OF BIRTH mgs on, ew TO
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER 5t h Ry
ep en an
A. NAME USA
B COUNTRY OF BIRTH
4. EMPLOYMENT
Truck Driver
A USUAL OCCUPATION M 0 n't Ob'" f
agazlne ul5 n ulor5 nc.
8. TYPE OF IND~TRY OR ~INES~, .....
Drom< New T 0./\
5. PLACE OF BIRTH '
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
Edgardo Pacheco
A. NAME USA
B. COUNTRY OF BIRTH
7. MOTHER Mym B
a orras
A. MAIDEN NAME USA
B COUNTRY OF BIRTH I
8 NUMBER OF THIS MARRIAGE
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV(fCE CIVIL A~ULMENT
17. MOTHER
Carol Fabiano
A. MAIDEN NAME
USA
B. COUNTRY OF BIRTH I
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIjORCE CIVIL A~ULMENT
D'(tTH
DljTH
8. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
8. HOW 010 LAST MARRIAGE END? (3) 0 DiVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) C DEATH
MONTH DAY YEAR
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
1ST
2ND
3RD
o
o
o
w
en
z
w
U
:i
o
o
o
o C
C D
o 0
C 0
o legal impediment exists
21 SIGNATURE OF GROOM ~
2. SIGNATURE OF BRIDE ~
23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta
Relations Law ~11 to perform marriage ceremonies within
o If checked, this license is t
24. TOWN OR CG18LERK
NAME (PRINT)
-
of the bride and groom named above by any person authorized
ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
be used only for the purpose of a second or subsequent ceremony.
25. A SOLEMNIZATION PERIOD BEGINS
by New York Domestic
~
{ SEAL }
~
ZIP
04/11/2002
DATE
er Falls, NY 12590
YEAR
MONTH
YEAR
2002 06
10 2002
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
STATE
27 TYPE OF CEREMONY
O)(.RELlGIOUS
9 0 OTHER, SPECIFY
1 D CIVIL
28. PLACE WHERE MARRiAGE OCCURRED
A STATE NEW YORK B. cou~ftj'R S ~
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
C CITY OF )( TOWN OF c: VILLAGE OF
SPECIFY Eft'5~ F ( S H k I L i..-
t HC'fe ......dl .:Tu...i\<:,,-t., C' k
26. SOLEMNIZATION OCCURRED
TIME MO DAY YEAR
29 OFFICIANT
NAME (PRINT)
TITLE
~A..J(c)
DATE
/..fo peWt:L i...
.JcT;
STATE
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
NAME (PRINT)