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COUNTY
cmarawN
DISTR.\;T
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Dominador Amilcar
r STATI:. "I~ NU"D~"
(THIS SPACE FOR STATE USE ONLY)
/~I,'lo.ci9
L Q SUPPLEMENTAL FILE ~
Dutchess
Wappinier
1368
130
MIDDLE
CURRENT SURNAME
FROM THE BRIDE
Corina Kay
FIRST MIDDLE
Nelson
CURRENT SURNAME
Pasa, III
11. A. FULL NAME
A. FUll NAME
FIRST
B. BIRTH NAME MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE P asa
'OPTIONAL. SEE REVERSE) 518 96 2 7
D. SOCIAL SECURITY NUMBER - - 3 9
12. RESiDENCE.... New York B Dutchess
,STATE) (COUNTY)
C. CHECK ONE [] CITY [] TOWN ~ VilLAGE
~~C:FY Wappingers Falls
o STREET ADDRESS 1 Gilmore Blvd. ZIP 12590
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? x: YES [] NO
13.A. AGE 29 13.B.DATEOFBIRTH March /12 /1971
MONTH DAY YEAR
Q.
N
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 115 -6 2 -4 5 26
D. SOCIAL SECURITY NUMBER
New York Dutchess
(STATE) (COUNTY)
[J CITY C TOWN X VilLAGE
Wappingers Falls
D STREET ADDRESS 1 Gilmore Blvd.
2. RESIDENCE A.
C. CHECK ONE
AND
SPECIFY
ZIP 12590
3. A. AGE
29
June
MONTH
14. EMPLOYMENT
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Dental Assistant
B. TYPE OF INDUSTRY OR BUSINESS Mid Hudson Dental
15. PLACE OF BIRTH Marion County, Oregon
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Au to Technician
B. TYPE OF INDUSTRY OR BUSINESS Wapp. Falls, Toyota
5. PLACE OF BIRTH Bronx, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Robert Clinton Nelson
Oregon, USA
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
i. MOTHER
A. MAIDEN NAME
B COUNTRY OF BIRTH
Dominador C. Pasa, Jr.
New York, New York
Charlotte Jane
Washington,
Second
Lantzer
USA
Anna Milagros Arroyo
New York, New York
First
18. NUMBER OF THIS MARRIAGE
8. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
One
DEATH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END?
3\ = DIVORCE
(31 L ANNULMENT
/ /
(2) [] DEATH
B. HOW 010 ~~S7 '~ARRIAGE END? 13) Xi DIVORCE 31 = ANNULMENT 2', - DEATH
C. DATE _~ST MARRIAGE ENDED? March / 19 /1998
MONW DAY v EAR
D. ARE ~NY ",GRMER SPOUSE(S) ALIVE? ~ YES = NO
20. IF PREVIOuSLv DIVORCED OR ANNUlED, PROVIDE THE FOllOWING INFORMATION
:lATE OF :lECREE PLACE ISSUED AGAINST WHOM
,MC"'TH JAY YEAR) iCITY. STATEiCOUNTRY, IF NOT USA\ SELF SPOUSE
3/19/98 Sacramento, CA
,~. DATE LAST MARRIAGE ENDED?
YEAR
MONTH DAY
D ARE ANY FORMER SPOUSEIS) ALIVE? = YES = NO
'O.F PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY, STATE COUNTRY. IF NOT USA) SELF SPOUSE
x=
1ST
2ND
3RD
:J
1ST
2ND
3RD
4TH
lief that the information I provided is true a
c-
o
o
TURE OF BRIDE ~
4TH
I. being duly sworn, depose and say, that to the best of my knowledge a
as to my right to enter into the a 'age stat~.
21 SIGNATURE OF GROOM ~
w
(J)
Z
W
o
::::i
. RNTNAE
"". SUBSCRIBED AND SWORN TO BEFORE ME Deputy Town A
SIGNATURE OF TOWN OR CITY CLERK ~ D E ug.
This license authorizes the marriage in New York St e 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.
[] 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
Ela" e Town Clerk
DATE 8/7 /00
12590
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON'
~
{ SEAL }
~
NAME (PRINT)
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
SIGNATURE ~
MAJ1.ING ADDRE
1'0 Box
SET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
1 : 00 PM
6
00
8
8
00
10
NY
TA
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
"P
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~I:"--
C. lOCATION OF CEREMONY ., ~
(CHECK ONE ANDYPECIFY)
o CITY OF ~OWN OF :: VilLAGE OF
Jiyt>t ~,c.
1~
fl0
NAME (PRINT)
SIGNATURE.
DQH.98 (1198)
SIGNATURE .