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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Luis Alberto Ramirez Ruiz
MIDDLE CURRENT SURNAME
Dutchess
COUNTY
wappinger
CITYfTO~N
DISTRICT'I jo8
NUMBER
REGISTER 2j
NUMBER
1. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL, SEE REVERSEL....
D. SOCIAL SE~RITY NUMBER xxx-XX - XXXX
2. RESIDENCE A. Y B. Dutchess
(STATE) YI (COUNlY)
C. ~~6CKON~. hl,D, CITY 0 TOWN 0 VILLAGE
SPECIFY r IS "II
f2 Old Glenham Rd
D. STREET ADDRESS ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED V~LAGE? 60
3. A. AGE25 3B. DATE OF BiRTH 0 /1
MONTH DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Cook
B. TYPE OF INDUe)RY OR BUS~SS uouole u
5. PLACE OF BIRTH axaca, eXlco
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Ruben Ramirez Mendoza
B. COUNTRY OF BIRTH MexIco
7. MOTHER D I R ' C
A. MAIDEN NAME 0 ores UIZ ontreras
B. COUNTRY OF BIRTH MeXICO
1
8. NUMBER OF THIS MAR81AGE
12524
.,
Y/f9~~
YEAR
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL A"l)'ULMENT
DlfTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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. STATEICOUNTRY. IF NOT USA) SELF SPOUSE
YEAR
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
Lo
~
SUPPLEMENTAL FILE
FROM THE BRIDE
Ericka Muniz Sanchez
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME)..If DIFFERENT
Kamlrez
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) XXX-XX _ XXXX
D. SOCIAL s~r NUMBER Dutchess
12. RESIDENCE A. B.
(STATE) .~ (COUNTY)
C. ~6CK ~fshkirr CITY 0 TOWN 0 VILLAGE
SPECIFY 7'2 Old <31t::lllli:llll RJ 12524
D. STREET ADDRESS ZIP .;
E. IS RIiqI~ENCE WITHIN LIMITS OF CITY OR INCORPORAft) VILLAGEh.A 0 Y~ &0
13. A. AGrf: 3B. DATE OF BIRTH ~ ~
MONTH DAY YEAR
14. EMPLOYMENT U I d
nemp oye
A. USUAL OCCUPATION
B. TYPE OF IND\lJi1We9'6~USM'~~ico
15. PLACE OF BIRTH '
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER M I' M . T
arce !nO umz orres
A. NAME Mexico
B. COUNTRY OF BIRTH
17. MOTHER
Avinada Sanchez Juarez
A. MAIDEN NAME r1 I
v ex co
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
Cfi'ORCE CIVIL AtfULMENT
DO"TH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. -.~ YEAR
B. HOW 010 LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
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) (CITYICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose a
as to my right to enter Into e ma.
21. SIGNATURE OF GROOM
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
e best of my knowledge and belief that the Information I provided Is tr
o 0
o 0
o 0
o 0
and that I dBclare t at no legal impediment exists
23. SUBSCRIBED AND SWORN TOI FFIRMED
SIGNATURE OF TOWN OR CI 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 onl for the purpose of a second or subsequent ceremony.
24. TOWN OR Clj" LER 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) n
W
en
z ~
W
~ { SEAL }
'-y-I
SIGNATURE ~
MA~~Groo
04/05/2010
DATE
I NY 12590
YEAR
06
04 2010
ZIP
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 0 RELIGIOUS
9 0 OTHER, SPECIFY
l~IL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY.D u-rlp) 5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY J p.. .pp r t-J C e 15 flu {, 5
o
IP
31. WITNESS TO <!:EMONY
NAME (PRINT) '~ " '-^ t.. \ \' 0
<2.0,"..\-es
L
SIGNATURE~