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COUNTY Dutchess
CITYITOWN Wappinger
DISTRICT1368 '
NUMBER
REGISTER40
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Steven Michael Caban
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica Collazo
---.J
1 , A, FUll NAME
11, A, FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
0-
N
: :::;:~~:~::::~g"~~~-Caban
(OPTIONAl- SEE REVERSE'-! 00-62-0755
0, SOCIAL s~q\lflJTY NUMBER
NY uutcness
12, RESIDENCE A, B,
(STATE) It/. (COUNTY)
C, CHECK QtiE, 0 CITY 0 TOWN 0 VILLAGE
~~~CIFYvvapplnger
I A Canterbury Lane 12090
0, STREET ADDRESS ZIP
.,
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORA(f~ VILLAGE)o 0 Yje9ffO
13, A, AG~1 3B. DATE OF BIRTH --
MONTH DAY YEAR
B, BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl- SEE REVERSE1 08-76-2461
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE).L. (COUNTY)
C. CHECK ONE 0 CITY~U TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 1 A Canterbury Lane
ZIP 12b~U
01..
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
03 /04 /1987
DAY YEAR
3. A. AGE23
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
l\Iurse
A. USUAL OCCUPATION' ~ rl I h C
ea tare
B. TYPE OF INDI,I$TRY OR 1iu.c;INESS
15. PLACE OF BIRTHtsronx, NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER .
A. NAM~ngel Dominguez
U~A
B. COUNTRY OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Construction Worker
B. TYPE OF INDUSTRY OR BUSINESS Construction
5. PLACE OF BIRTH Bronx, Ny
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Steven Michael Caban
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Angella Hazim
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
17. MOTHER E I Collazo
A. MAIDEN NAME ve yn
U~A
B. COUNTRY OF BIRTH I
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DffoRCE CIVIL A~ULMENT
DrtTH
011 TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(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) (CITYICOUNTY. 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 ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
1ST 0 0 1ST
2ND 0 0 2ND
~ 0 0 ~
~ 0 0 ~
I duly swear/affirm. dep.ose and say, that to the best of my knowledge and belief that the information I provided is tr
as to my right to enter into the marr ge state.
21. SIGNATURE OF GROOM.
W
en
z
W
(,)
::i
SE
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 b authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YOR ATE 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
J C Masterson
MONTH
YEAR
~
{ } NAME (PRINT)
SEAL SIGNATURE ~
'-v-I MA~~GIOWd1
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME
MONTH
YEAR
28 2010
AM 04
02:56 PM
30
2010
06
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY O(()..~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOW~ VILLAGE OF
SPECIFY r1o~o fYlEo/
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
ZIP
"W"""'~~^ &
NAME (PRINT) '-
SIGNATURE~ C4~Ml 5/;A"