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COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT1368 c
NUMBER
REGISTER 51
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Victor Israel Vazquez
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melinda Rose Wareing
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
1. A. FULL NAME
FIRST
..
N
B. BIRTH NAME (MAIDEN NAME\'I DIFFERENT
C. SURNAME AFTER MARRIAGE azquez
(OPTIONAL - SEE REVERSE~ 20-76-9221
D. SOCIAL S~C.\lRJlY NUMBER
12. RESIDENCE AN Y Buutchess
(STATE) .t. (COUNTY)
C. CHECK Ql:lE k 0 CITY 0 TOWN 0 VILLAGE
~~CIFYl:See man
1 09 Stagecoach Pass
D. STREET ADDRESS
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) xxx-xx-xxxx
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) .L. (COUNTY)
C. CHECK ONE 0 CITY 0 TOWWU VILLAGE
~~CIFY Wapping_ers Falls
D. STREET ADDRESS 2595 south Avenue; Apt 1 ZIP 1lo~U
E. IS RESIDENCE WITHIN LIMITS OF CI1Y OR iNCORPORATED VILLAGE? ~ YES 0 NO
05 /29 /1986
DAY YEAR
..,
E. is RESIDENCE WITHIN LIMITS OF CI1Y OR INCORPORA(fl7VILLAGE? 0 Yj9810
13. A. AG~2 3B. DATE OF BIRTH p9
MONTH DAY YEAR
14. EMPLOYMENT .
A. USUAL OCCUPATIONQuahty Control
vonsuuctlon
B. TYPE OF IND~TRrtfcR B~iIN~~
15. PLACE OF BIRTH 0 an ,
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMEPaul Allan Wareing, Jr.
. B. COUNTRY OF BIRTHU ~ A
3. A. AGE 23
38. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Mechanic
B. TYPE OF INDUSTRY QR BU~NESS Auto
5. PLACE OF BIRTH MeXICO ity, MeXICO
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Victor Vazquez-Romero
B. COUNTRY OF BIRTH MeXICO
7. MOTHER
A. MAIDEN NAME Celia Sandoval-Rodriguez
B. COUNTRY OF BIRTH Mexico
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
17. MOTHER L' M . M ' II'
A. MAIDEN NAME on ane anglne I
B. COUNTRY OF BIRTHU ~ ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D80RCE CIVIL A~ULMENT
D'(t TH
Di1TH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
~ YEAR
B. HOW DID 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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
B. 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 ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
o
o
a:
w
III
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::!
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1ST
2ND
3RD
4TH
I duly swear/affirm, i:teP.Ose and say, that to th
as to my right to enter into the marn e S
_~SJGNA'TuRE:OF G$lOOU" .
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
knowledge and belief that the information I provided i
DATE
by New York Domestic
+
23. SUBSCRIBED AND SWORN TO/AFFIRMED BE
SIGNATURE OF TOWN OR CITY CLERK,-
This license authorizes the marriage in New York State 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.
,-I'-.. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Mast
{SEAL SIGNATURE'- DATE 05/12/2010 TIME MONTH YEAR
'---- -.J MA~tf~cfdt ush Rd, Wappingers Falls, NY 12590 AM 05 13 2010
-v- 01:46pM
STREET CITYITOWN STATE ZIP
~~~R~~RT~~J IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M . AY YEAR 0 il\ RELIGIOUS
DATE AND AT THE TIME AND AM ~ -?.-..
PLACE INDICATED. "'3 J -S 0 VVlO 9 0 OTHER, SPECIFY
07
11 2010
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNrv'\).rtc\'(;1~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~~~:~~~~~\(AAa. ~~lXe..
SIGNATURE'- ~~
MA~~3D~t~X' ~~~
STREET CITY/TOWN
30. WITNESS TO C
~~\OL
sl~~D
I, ?J:;1:J;;>
SPECIFY
'"'\~~
TITLE
WN OF 0 VILLAGE OF
DATE
rJ'-\
S",.TE
ZIP
31. WITNESS TO CEREMONY..,.
o
NAME (PRINT)
SIGNATURE'-