100
p o~
I '
......
C""l
o
\0
N
-
!Z ~
m~ :>
Ml~ c(
00 C
5~ w-
o ,,1.1.
~)ju.
zaJ~c(
QZ ~
i ~ g
~ QJ ~
".... lJ
~CIl
wQ..
~~
;;~
.c::
bO
;:l
~Z
g; --
:r...
w~
~;:l
0::0
~Ua::
~ :Jj
i:l..c:: ~
w Z
0::.... 0
8= ~
.. ...
~r"*
frl ti;
"-
rn
Zzz
~!::Q W
~~... ~
~~~ c(
~~~
:;)()W g
2';1~ 1.1.
" i=
~ a:
~g~
...z'"
i~~
1. A. FULL NAME
S1 A 1E OfNEW~YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Charles Henry Velazquez
FIRST MIDDLE CURRENT SURNAME
MIDDLE
I
STATE FILE NUllBER
(THIS SPACE FOR STATE USE ONLY)
I
COUNTY Dutchess
~.70WN Wappinger
~1f:ec: 1368
~~~~R 100
/.I"~OO
L 0 SUPPLEMENTAL FILE
~
FROM THE BRIDE
Karen
FIRST
Rodriguez
CURRENT SURNAME
11. A. FULL NAME
a.
N
BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAMEI, IF DIFFERENT
C. SURNAME AFTER MARRIAGE Rodriguez-Velazquez
(OPTIONAL. SEE REVERSE) 083 58 4709
D. SOCIAL SECURITY NUMBER - -
12. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY Xl TOWN 0 VILLAGE
~~CIFY Poughkeepsie
o STREET ADDRESS 7 High Court ZIP 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILlLAGE? 0 YES Xl NO
13.A. AGE 25 13.B.DATEOFBIRTH June /10 /1975
~Tlt... OAY YEAR
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
2. RESIDENCE A. New York B Dutchess
(STATE) . (COUNTY)
[! CITY ~ TOWN 0 VILLAGE
Poughkeepsie
o. STREET ADDRESS 7 High Court
077-54-2028
C. CHECK ONE
AND
SPECIFY
ZIP 12603
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/ 13 /1961
OAY YEAR
3. A. AGE
39
3B. DATE OF BIRTH
June
MONTH
4. EMPLOYMENT
14. EMPLOYMENT
w
...
..
...
'"
A. USUAL OCCUPATION Computer Consultant
B. TYPE OF INDUSTRY OR BUSINESS Self-Employed
5. PLACE OF BIRTH Manhattan, New York
(CITY. STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Secre tary
B. TYPE OF INDUSTRY OR BUSINESS Macia Consulting
15. PLACE OF BIRTH Bronx, New York
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
16. FATHER
A. NAME
Charles
USA
Velazquez
Ruben Rodriguez
Puerto Rico
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
Florence Lydia Cintron
Milagros Rodriguez
Puerto Rico
First
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
USA
First
18. NUMBER OF THIS MARRIAGE
B. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE 131 C ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
(2) C DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH OA Y YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? == YES ': NO
1 D. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
IMONTH, DAY. YEAR) ICITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
,3) ;: ANNULMENT
/ /
121 ::::: DEATH
w
en
z
w
o
::::;
1ST C 1ST
2ND ::J 2ND
3RD -, -, 3RD C
4TH -, C 4TH C
I, being duly sworn, 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 m riage st e. .
21 SIGNATURE OF GROOM. 22. SIGNATURE OF BRIDE.
... USE CURRENT NAME
23. SIGNATURE OF TOWN OR CITY CLERK. Clerk DATE June
This license authorizes the marriage in New York St te of the bride and groom named above by any person authoriZ(ld by New York Domestic
Relations Law ~11 to perform marriage ceremonies within Ne~ York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the pu se of a second or subsequent ceremony.
24. TOWN OR CLERK 25. A. SOLEMNIZAIION PERIOD BEGINS
laine H. Snowden Town Clerk
DATE 6/22/00
NY 12590
,....
'--'
25. B. SOLEMNIZATION PERIOD
ENOS AT MIDNIGHT DN:
,-'-,
{ SEAL }
~
NAME (PRINT
YEAR
TIME
MONTH
YEAR
MONTH
DAY
SIGNATURE.
MAILING ADORE
PO Box 324
s
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA TED.
AM
12 :45PM
6
8
23
00
21
00
in ers'Falls
I
26. SOLEMNIZATION OCCURRED
1M DA YAR
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF Ijl TOWN OF 0 VILLAGE OF
SPECIFY ;Pb~~~ ~
27. TYPE OF CEREMONY
o r'!!-flELlGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAqE OCCURRED
1 C CIVIL
'J>w.-+( "'~
110
29. OFFICIANT
-p ...~ +"."...
TITLE
NAME (PRIN
SIGNATURE.
DCJH.8ll (1111I8)