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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Christopher Derek Cuadrado
FIRST MIDDLE CURRENT SURNAME
COUNTYDutchess
CITYfTOWN Wappinger
DISTRI~ 368 .
NUMBER .
REGISTEFQO
NUMBER
1. A. FULL NAME
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERS't>90_78-1 025
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA.NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 crrI"'o TOWN 0 VILLAGE
~~~CIFY Wap~inger
D. STREET ADDRESS 07 Myers Corners Rd
ZIP llol:lU
trI
E. IS RESIDENCE WITHIN LIMITS OF CIlY OR INCORPORATED VILLAGE? 0 YES 0 NO
05 /01 /1981
OAY YEAR
3. A. AGE28
3B. DATE OF BIRTH
MONTH
I
STATE FILE NUM8EH
(THIS SPACE FOR STATE USE ONL Y)
4. EMPLOYMENT
A. USUAL OCCUPATION Banker
B. TYPE OF INDUSTRY OR BUSINESS Banking
5. PLACE OF BIRTHManhattan, Ny
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Derek Joseph Cuadrado
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Ellen Medico
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
Di)TH
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ashley Candice Hill
-1
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITYICOUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
11. A. FUll NAME
CURRENT SURNAME
FIRST
MIDDLE
B. BIRTH NAME (MAIDEN NAMEtr DlF'dRECi
C. SURNAME AFTER MARRIAGE ua ra 0
(OPTIONAL - SEE REVERS'544-BO-03 {!:S
D. SOCIAL S~~~ NUMBER umano
12. RESIDENCE ~ B.
(STATE) trI (COUNTY)
C. CHECK PM~ t 10 CITY 0 TOWN 0 VILLAGE
AND p/::....a er 00
SPECI 83 Pine Meadow CI~s~lll
D. STREET ADDRESS
E. IS R~~ENCE WITHIN LIMITS OF CITY OR INCORPORA{Ef VILLAGE~ F. 0
13. A. AGf: 3B. DATE OF BIRTH L
MONTH DAY
14. EMPLOYMENT T h
A. USUAL OCCUPATIOrPance Ceahc er h
oreograpller
B. TYPE OF INW~M)~8~SI~~n
15. PLACE OF BIRTH '
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER 1\11 k HOII
A NAM~...:ar I
. . Canada
B. COUNTRY OF BIRTH
tJ2T1M
ZIP
.,
Y~~6NO
YEAR
17. MOTHER J' B I
amce eas ey
A. MAIDEN NAME
B. COUNTRY OF BIRT~ana~a
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
~ORCE CIVIL ~NULMENT
OO"'TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY' '. ~ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3AD
4TH
I duly swear/affirm, depose and say 0 th
as to my right to enter into the ma age state
21. SIGNATURE OF GROOM~
o 0 1ST 0 0
o 0 ~D 0 0
o 0 3RD 0 0
o 0 4TH 0 0
edge and belief that the information I provided is true and that I declare that no leQ,al impediment exists
.SIGNATUREOFBRIDE~ CD !Zl~-~
~CURRENTNAME 03/19/2010
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE 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
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
{ } NAME (PRINT) J
TIME MONTH YEAR
SEAL SIGNATURE ~
\...- -..J MA~I~GrOO'fn AM 03 20 2010
-v- 12:02 PM
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE o~ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. , 0 9 0 OTHER, SPECIFY
DATE
by New York Domestic
MONTH
YEAR
05
18 2010
2B. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY O(L~1U6(;"
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~'TOWN OF 0 VILLAGE OF
SPECIFY IV E {/J /)J I ~ Qf/JJe
Ih.Jfh~ IJ V 's f f 'er<. 9
NAME (PRINT)
SIGNATURE~