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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FIRST Robertll[i~ymond ~O~~9NAME
COUNTY Dutchess
CITYn-OWN Wappinger
~~~:~c; 1368
~~~I~~~R 147
1 . A. FULL NAME
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER OfiO-RO-?01 g
2. RESIDENCE A. N):TATE) B. l?dMess
c. CHECK ONE 0 CITY o/ZJ TOWN 0 VILLAGE
AND 'A' .
SPECIFY vv~ppmoer
D. STREET ADDRESS g F Pembroke Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES t'J NO
3 A. AGE 21 3B. DATE OF BIRTH MO~~ / DQp / yl~89
4. EMPLOYMENT
A. USUAL OCCUPATION .Army National GI18rd
B. TYPE OF INDUSTRY OR BUSINESS Milit~ry
5. PLACE OF BIRTH ~1~~~TIo /~~NTRY IF NOT USA)
6. FATHER
A. NAME Robert Santiago Ir
B. COUNTRY OF BIRTH I J S A
7. MOTHER
A. MAIDEN NAME YVF'!ttP. T nrrp.~
B. COUNTRY OF BIRTH I J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
....
:;
c(
c
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LI.
-c(
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
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
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
S~brin~ ,f~~e Ortiz-q~R~~~~~gAME
~
11. A. FULL NAME
FIRST
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE S~nti~gn
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 072-76-9404
12. RESIDENCE A. NY B. Dlltchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 9 E Pembroke Circle ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/04 A 986
DAY YEAR
13. A. AGE 24
O~
MONTH
13B.DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Security Officer
B. TYPE OF INDUSTRY OR BUSINESS Entergy
15. PLACE OF BIRTH ~I~~~TE ~NTRY IF NOT USA)
16. FATHER
A. NAME .Jn~e Alberto Ortiz
'B. COUNTRY OF BIRTH USA
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
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
a:
w
~
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Z
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Z
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a::
Iii
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
of my knowledge and belief that the information I provided is true and tha
USE
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the ~riage 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
{ } NAME (PRINT) John C. Mas
TIME MONTH YEAR
SEAL SIGNATURE. DATE 10/21/201
MAILING ADDF~E~S 11 : 08AM
"-v-I 20 Miaale in ers Falls NY 12590 PM 10
STREET CITYITOWN STATE ZIP
~~~R~:RT~~~ IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 00 RELIGIOUS 1 ~VIL
DATE AND AT THE TIME AND
PLACE INDICATED. II '.40 PM 10 2- I ;)..O/{) 90 OTHER, SPECIFY
21. SIGNATURE OF GROOM~
TITLE
NAME (PRINT)
SIGNATURE.
DOH-98 (09/2009)
DATE
10/21/2010
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
21
2010
19 2010
12
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~v't"Cl\e I)~
'7ZJvv {\ C. L e a.. K
/o{-z.. t I L(') /0
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY W ,'\(II? \ '~0 e.(L.
31.
NAME (PRINT)
SIGNATURE.