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COUNTY Dutchess
CITYfTOWN Wappinoer
~~~:~c: 1368 .
~~~~~~R 139
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Willi;:lm Thom;:l~ Hooten
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL YI
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Nashly M~~erline GcmR~~~~~NAME
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1. A. FULL NAME
11. A. FULL NAME
FIRST
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N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 055-80-7829
2. RESIDENCE A. NY B. D\Jtche~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN ~ VILLAGE
~~~CIFY W;:lppingers Falls
D. STREET ADDRESS 6 Upper Henry St ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? I!f YES 0 NO
3. A. AGE 19 3B. DATE OF BIRTH Ofi /?R / 1991
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Hooten
(OPTIONAL - SEE REVERSE) xxxxxxxxx
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 1'!'1 VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 6 Upper Henry St
ZIP 12590
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 20 13B.DATE OF BIRTH 11 /21
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Office Assistant
B. TYPE OF INDUSTRY OR BUSINESS Maintenance
15. PLACE OF BIRTH Guayaauil. Ecuador
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Wilson Gonzabay
'B. COUNTRY OF BIRTH Ecuador
YES 0 NO
/f 989
YEAR
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4. EMPLOYMENT
A. USUAL OCCUPATION .I;:lnitor
B. TYPE OF INDUSTRY OR BUSINESS Maintenance
5. PLACE OF BIRTH Carmel, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Thom::l~ .J;:lme~ Hooten
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Elizabeth M. Serapin
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
C3
17. MOTHER
A. MAIDEN NAME Dora Padilla
B. COUNTRY OF BIRTH Ecuador
lB. 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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (31 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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
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
W
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the best 0
as to my right to enter into the .
21. SIGNATURE OF GROOM ~
USE CU
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
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN
o If checked, this license is to be used only for the purpose of a sec
~ 24. TOWN OR CITY CLERK
} NAME (PRINT) John C. Masterson
{ ~
SEAL SIGNATURE~ DATE 10/06/201
I....- -J MAI~ 6qol'F\E~e AM
-v- LU MICalE sh Rd, Wappingers Falls, NY 12590 01:17PM
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 IL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B.COUN~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) //
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY ~1rPP 1tV6~ ~
o
o
o
1ST
2ND
3RD
DATE 10/06/2010
by New York Domestic
YEAR MONTH
YEAR
MONTH
10 07 2010 12 05 2010
NAME (PRINT)
SIGNATURE~