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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Luc~ofplani HerQi~~NAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~: 1368
~~~I~J~R 125
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER fi76-4.1-74.4.0
2. RESIDENCE A H&TATE) B. ~~IIIIII
C. CHECK ONE IiOi! CITY 0 TOWN 0 VILLAGE
AND
SPECIFY Honoll IIII
o. STREET ADDRESS 4.7-4.16 A W::lihAA Rd
ZIP 96744
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 0 YES I!'f NO
MoS)l / o~O / yJA~80
3. A. AGE 30
3B. DATE OF BIRTH
....
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4. EMPLOYMENT
A. USUAL OCCUPATION Electrician
B. TYPE OF INDUSTRY OR BUSINESS r.on~tn Ir:tion
5. PLACE OF BIRTH K8ill 1::1 H::IW::Iii
(CITY, STATE'/ COUNTRY IF NOT USA)
6. FATHER
A. NAME .Arthur G Hernandez
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME C::Irmell::l W r.::Imm::lr::lt::l
B. COUNTRY OF BIRTH I J S A
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
12) 0 DEATH
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
R5?b~~P HAnnA~b'j'RENT SURNAME
-1
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~(Mr~~rt~~C~~SE~ernandez
D. SOCIAL SECURITY NUMBER 585-45-2819
12. RESIDENCE A. HI B. Honnll 111 I
(STATE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Honoluh I
D. STREET ADDRESS 47-416 A Waihee Rd ZIP 96744
E. IS RESIDENCE WITHIN liMITS OF CITY OR INCORPORATED VILLAGE? 0 YES I!l' NO
/?3 A q7f1
DAY YEAR
13. A. AGE 33
11
MONTH
13B.DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION TA::lr.hAr
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH Albua uemue, New Mexico
(CITY, ST AfE / COU~TRY IF NOT USA)
16. FATHER
A. NAME Thom::l~ 1= HAnnA~~y
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Mary Ellen Kearney
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. 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 (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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
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1 ST 0 0 1 ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
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 decl
as to my right to enter into the marriage sta . '
21. SIGNATURE OF GROOM~
o 0
o 0
o 0
o 0
re that no legal impediment exists
SE CUR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
DATE
by New York Domestic
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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
C
SIGNATURE DATE 09/07/201
MAILING A RES ,
20 . ebush Rd. W poinaers Falls. NY 12590
STREET CITYITm::iN STATE ZIP
~~~R~~~RT~~J IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 'tl{ RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. I ~ 10 9 0 OTHER, SPECIFY
~
{ SEAL }
'-v-I
SIGNATURE~
DOH.98 (09/2009)
TIME
MONTH
YEAR
MONTH
YEAR
11 :4&M
PM
09
08
2010
11
06 2010
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY W t"lfr; n tll!... r
NAME (PRINT)
SIGNATURE~