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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THM~q9Jripe
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STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
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Dutchess
COUNTY 'J/oppinger
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~~~'~~~R 18
NUMBER
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L 0 SUPPLEMENTAL FILE
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FROM.THE BBIDE
. ~IMrnfN". Mfranda
A FULL NAME
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
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8 BIRTH NAME, IF DIFFERENT
(STATE) (COUNTY)
C ~~6CK OWappm~~r 0 TOWN 0 VILLAGE
SPECIFY 48 Old Route ~
D STREET ADDRESS
(STATE) (COUNTY)
C ~~6CK CWappm~ 0 TOWN 0 VILLAGE
SPECIFY 48 Old Route 9
D STREET ADDRESS
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E IS R"3~NCE WITHiN LIMITS OF CITY OR iNCORPORATEltnLAGE? 190 YES 1969
3 A. AGE 3B. DATE OF BIRTH / /
MONTH DAY YEAR
4. EMPLOYMENT Baker
A USUAL OCCUPATION Dunkin Donut3
B TYPE OF INDWXRftf'eftYS
5. PLACE OF BiRTH
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER Gonzalo Felipe
A. NAME Me-xieo City
8. COUNTRY OF BIRTH
E. IS RE:f.3NCE WITHIN LIMITS OF CITY OR INCORPORATE(l!}LAGE?}8 0 Y6fd<<ffO
13. A. AGE 13.B. DATE OF BIRTH _ L
MONTH DAY YEAR
14. EMPLOYMENT Cleaner
A. USUAL OCCUPATION Royal Cleaning
8. TYPE OF IND'M~,dtf{)l'eftVS
15. PLACE OF BIRTH
(CITY, STATE/COUNTRY IF NOT USA)
16 FATHER Timoteo Miranda
A. NAME Sanluis Potosi
B. COUNTRY OF BIRTH '
17. MOTHER
Cristina Miranda
A. MAIDEN NAME Mexico Cny
8. COUNTRY OF BIRTH 1
7. MOTHER Micaelina Ramirez
A MAIDEN NAME M~xit;(.I, Pu~bl~
B. COUNTRY OF BIRTH 1
8 NUMBER OF THIS MARRIAGE
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDEO BY
DIV(3RCE CIVIL A'()JULMENT
18 NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL A't)IULMENT
D'nTH
DU'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
/ /
(2) 0 DEATH
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
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
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1 5T 0 0 15T 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 that I declare that no legal impediment exists
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~;,{,,6 I'
22. SIGNATURE OF BRIDE ~
Si.to \'(10- \06tlYlC\ \.J,\'<OJ\ctn,
USE CURRENT NAME 02/27/2002
DATE
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23. SUBSCRIBED AND SWORN TO 8EFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York
Relations Law ~11 to perform marriage ceremonies wi
o If checked. this license
r-"-. 24 TOWN OR <6fc5tfljKJ. Morse
{ } NAME (PRINT) "'9~
SEAL . __~::;(. ~....c-.. UZf~/lUUl TIME MONTH
'-v-' ~U.h "G. ~ -:~-- ails. tW' 12590 3:29 :~ 02
STREET CITYfTOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27;;TY E OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 RELIGIOUS 1 0 CIVIL
DATE AND AT ThE TIME AND JH lAM
PLACE INDICATED ~ PM
28
2002 04
28 2 02
by New York Domestic
tate of the bride and groom named above by any person authorized
in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
to be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
25 8. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON
DAY
YEAR
MONTH
DAY
YEAR
28 PLACE WHERE MARRIAGE OCCURRED I
A. STATE NEW YORK 8. COUN~ u-rcl1 e ~
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
0,TY OF 0 TOWN OF 0 VILLAGE OF
SIGNATURE ~
~7ADwlt~w
STREET
30. WITNESS TO C EMONY
jSEIICf)N
SPECIFY
31. WITNESS TO
NAME (PRINT)
SIGNATURE ~
DOH-98 (1/98)
NAME (PRINT)
SIGNATURE ~