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COUNTY Dutchess
CITYfTOWN Wappinger
~~J~kc~ 1368 .
~~~I:J~R 94
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Habet! R~~mnnrl S::ln1i::l~r)
IDOL CURR NT RNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sabrina Rose Ortiz
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FUll NAME
FIRST
FIRST
11.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Orti7-~~nti~gn
(OPTIONAL. SEE REVERSE) 072 76 9404
D. SOCIAL SECURITY NUMBER _ - -
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY I!i'1 TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D. STREET ADDRESS 9 E Pembroke Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES ~ NO
/04 /i 986
DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 0"'0 80 ?O 19
D. SOCIAL SECURITY NUMBER _!:!- - -- - -- - -
2. RESIDENCE A. NY B. [1lltr.hp.~~
-m-T ATE) (COUN"'I'Y)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY ~rrlngAr
D STREET ADDRESS 9 E Pembroke Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 1!1 NO
3. A. AGE 20 3B. DATE OF BiRTH nA / n6 / 1 Q8Q
MON'fiT D7:y YEAli
13. A. AGE ?4
13B.DATE OF BIRTH
03
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Security Officer
B. TYPE OF INDUSTRY OR BUSINESS Entergy
15. PLACE OF BIRTH Bronx. Ny
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME JO~A Alberto Ortiz
'B. COUNTRY OF BIRTH U S A
17. MOTHER
A. MAIDEN NAME Rosa Iris Garcia
B. COUNTRY OF BIRTH Puerto Rico
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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C
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u.
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4. EMPLOYMENT
A. USUAL OCCUPATION Army N(3tinn~1 ~11~rrl
B. TYPE OF INDUSTRY OR BUSINESS Military
5. PLACE OF BIRTH ~~?~~~ /~NTRY IF NOT USA)
6. FATHER
A. NAME Robert S~nti(30n .Ir
B. COUNTRY OF BIRTH LJ S A
7. MOTHER
A. MAIDEN NAME YVAttA T arrAS
B. COUNTRY OF BIRTH LJ ~ A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
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) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
a:
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1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true a
as to my right to enter into the mage state. \
21. SIGNATURE OF GROOM~ \j-
us
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...QLEflK___ _ 25. A. SOLEMNIZATION PERIOD BEGINS-
C.
DATE
by New York Domestic
,-I-..
{ SEAL }
"-.t-I
NAME (PRINT)
MONTH
YEAR
YEAR
TIME
MONTH
SIGNATURE ~
MAILING AD
20
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
01 :28PM
07
29
2010
09
26 2010
28. PLACE WHERE MARRIAGE OCCURRED (
A. STATE NEW YORK B. COUNrvPlJt~./
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF )r{ TOWN OF . 0 ~GE OF
SPECIFYJt!.....MfJ tv ~
00 RELIGIOUS + 0 C~
9~OTHER, SPECIFY ~ 1tJ
ZIP
31. WITNESS TO CEREMONY
~t.,
NAME (PRINT)
SIGNATURE~