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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
JOr!:Je Luis Guzman
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT 1368 .
NUMBER
REGISTER 126
NUMBER
1 . A. FUll NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 1 03-58-0442
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY ~ TOWN D VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 6 Miller Dr
3. A. AGE 37
ZIP 12533
YES ~ NO
/ 1973
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? D
08 / 05
MONTH DAY
3B. DATE OF BIRTH
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4. EMPLOYMENT
A. USUAL OCCUPATION Juvenile Corrections
B. TYPE OF INDUSTRY OR BUSINESS Correctiions
5. PLACE OF BIRTH Bronx, New York
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Anthonv Guzman
B. COUNTRY OF BIRTH unknown
7. MOTHER
A. MAIDEN NAME Norma Carrillo
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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 STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Joanna Rose Lomedico
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Guzman
(OPTIONAL - SEE REVERSE) 132-74-6298
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A. NY B. Dutchess
(STATE) ~ (COUNTY)
C. CHECK ONE ~ CITY TOWN 0 VILLAGE
~~~CIFY East Fishkil
D. STREETADDRESS6 Miller Dr ZIP 12533
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED ViLLAGE? 0 YES ~ NO
/12 /1'984
DAY YEAR
13. A. AGE 26
01
13B.DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Practice Assistane
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Bronx, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Carmello Joseph Lomedico
'B. COUNTRY OF BIRTH Ita Iy
17. MOTHER
A. MAIDEN NAME Josephine Ann Sferruzza
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEaTH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) D 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
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o 0 ~D 0 D
o 0 3RD 0 D
o 0 4TH D D
knowledge and belief that the information I provided is true and that I declare tha no legal impediment exists
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09/08/201 0
DATE
by New York Domestic
YEAR MONTH YEAR
TE 09/08/201
ails, NY 12590
11 07 2010
STATE
27. TYPE OF CEREMONY
o ~L1GIOUS
9 0 OTHER, SPECIFY
ZIP
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~.:\f~i'<<,
C. LOCATION OF CEREMONY
(CHECK ONE AND.JPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY f1 t'-'\: i \\
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DATE~ ).o\l)
'{\UV ~r\.. \ :nUt
STATE ZIP
31. WITNESS T EREMONY
NAME (PRIND
SIGNATURE~
DOH.98 (09/2009)
NAME (PRIND
SIGNATURE~