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COUrtTY Dutchess
CITYfTOWN Wappinqer
1368
29
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John Rodriguez
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
DISTRICT
NUMBER
REGISTER
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Loretta K Cutrone
MIDDLE CURRENT SURNAME
~
A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rodrigl Je7
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER 065-70-6475
12. RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY D,",OWN 0 VILLAGE
AND W .
SPECIFY apprnger
D. STREET ADDRESS 95 - 57 New Hackensack
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 090-70-0059
o SOCIAL SECURITY NUMBER _ _ _
2 RESIDENCE A. N Y B. Dutchess
(ST A TEl (COUNTY)
C CHECK ONE 0 CITY L/""TOWN 0 VILLAGE
AND W .
SPECIFY applnger
o STREET ADDRESS 95 - 57 New Hackensack ZIP
ZIP 12590
DYES D.....NO
O~ /1979
DAY YEAR
12590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3 A AGE 24 3B. DATE OF BIRTH 03 /
MONTH
DYES c1'" NO E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE'
14 / 197 13. A. AGE ?? 13.B. DATE OF BIRTH 11 /
DAY YEAR MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION
14. EMPLOYMENT
Pre-loader
UPS
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Beacon. New York
(CITY, STATE/COUNTRY IF NOT USA)
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH Tarrvtown, New York
(CITY, STArE/COUNTRY IF NOT USA)
6. FATHER
A NAME Jose Rodriquez
B. COUNTRY OF BIRTH Puerto Rico
16, FATHER
A. NAME Jay Cutrone
8. COUNTRY OF BIRTH USA
17. MOTHER
7. MOTHER
A MAIDEN NAME Yolanda Campa
B. COUNTRY OF BIRTH Cuba
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
A MAIDEN NAME Rarhara M~ Cra~ken
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? 13) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
12) 0 DEATH
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE IS) 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
MONTH DAY YEAR
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
w
en
z
w
U
:J
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 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 )hat ~ declare thal)no leQal Impediment eXists
as to my nght to enter into the marr e ate. I / / 1 _ .!;.~_~ . I,?
21 SIGNATURE OF GROOM ~ 22 SIGNATURE OF BRIDE ~cX'-"'~ .Y "M/-.'":\ \ j 1 j~
. , - ~I1SE CUR1lENT~
23 ~~BJ;T~~~DO~NT~~~OtRN ~~yB C DATE 04/05/2002
This license authorizes the marriage in New York Sta of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o 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
ri
04/05/200
TIME
MONTH
~
{ } NAME (PRINT
SEAL SIGNATU';; ~
'-v-' MAI~a ~~drebus
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
10:09-M
PM
04
l~L
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT(PC,1Ctkt2J
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LLAGE OF
t.{} kP(Jr tv6~ t?A <r~
SIGNATURE
MAIL/JAD
STREET
30. WITNESS TO C
SPECIFY
ZIP
31. WITNESS TO CEREMONY /"
I r" r(
NAME (PRINT) U \ \ '1\ 1f
-'
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
((
!\~
\
SIGNATURE ~