086
COUNIY Dutchess
CITYfTOWN '^'appinger
DISTRICT . .
r \ NUMBER 1 JeS
/ , REGISTER
/ ,NUMBER 86
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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
8amu~J;}uij:ld:l J~A,URNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Elisa M~[!Cl r.~IIp. p~J~~~Or'1URNAME
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11. A. FUll NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
xxx-xx-xxxx
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER xxx-xx-xxxx
12. RESIDENCE ANY B nlltr.hp.~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWNIl] VILLAGE
~~~CIFYW~rringp.r~ Fall~
D. STREET ADDREss11 E Colonial Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ootJ YES 0 NO
/iF, ;(q46
DAY YEAR
2 RESIDENCE A. N'fsTATE) B. QM~~ss
C. CHECK ONE oil CIIY 0 TOWN 0 VilLAGE
AND
SPECIFY Poughkeepsie
o STREET ADDRESS 27 North Clo\ler St ZIP 1 ?Rn1
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
M~~ / ~AO / ~~3
13B.DATE OF BIRTH
nQ
MONTH
13. A. AGE63
3. A. AGE 56
4. EMPLOYMENT
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATIONHoll~P. r.lp.~np.r
B. TYPE OF INDUSTRY OR BUSINESS House Cleaning
15. PLACE OF BIRTH~c~~t~~E'/~~~R~~ NOT USA)
16. FATHER
A. NAMECarlos CClIlp.
B. COUNTRY OF BIRTI-L.mknown
17. MOTHER
A. MAIDEN NAMEAbigail Palacios
B. COUNTRY OF BIRTrEcuador
18. NUMBER OF THIS MARRIAGE 2
A. USUAL OCCUPATION Pastry Cheif
B. TYPE OF INDUSTRY OR BUSINESS Culinary
5. PLACE OF BIRTH ~1;l;i,qMp;lM!i,Si~~Irala
6. FATHER
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A. NAME Clemente Quijod:l
B. COUNTRY OF BIRTH EI Salvador
7. MOTHER
A. MAIDEN NAME Uvilia Jordan
B. COUNTRY OF BIRTH EI Salvador
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH
1 1 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) g DEATH B. HOW DID LAST MARRIAGE END? (3) t!1 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 04/ ()4 / ?n04' c. DATE LAST MARRIAGE ENDED? 11 / 06 / 2001
MONTH D~ ~~ MONTH DAY - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? D YES ~NO D. ARE ANY FORMER SPOUSE(S) ALIVE? ~YES 0 NO
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10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 11/06/2001 Victoria Del Portet 0 I!'l
2ND 0 0 2ND 0 D
3RD 0 0 3RD 0 D
4TH 0 0 4TH 0 D
I duly swear/affirm, 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 stat~. , J d f'\ ~ Q
21. SIGNATURE OF GROOM" e L. U \ ~ AIGNATURE OF BRIDE" 81" S' A- /.. 1\ II (J ~
USE ' US~.cLJR=t ~AME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 07/19/2010
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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
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{ SEAL }
'-.t-'
NAME (PRINT)
TIME
MONTH
YEAR
MONTH
YEAR
AM
12:02PM 07
2010
09
17 2010
20
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~""""R.""'"
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF~ I UWN Uf' P(VILLAGE OF
SPECIFY~~\~('~ ~~
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
NAME (PRINT) ·
SIGNATURE~ ·