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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c; 1368 .
~~~liJ~R 113
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Aram Noel PAa~~~
MI U SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Sarita Green
MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 091-74- 2 843
2. RESIDENCE A. N;YrATE) B. gJd~~ress
c. CHECK ONE 0 CITY lli!' TOWN 0 VILLAGE
AND W .
SPECIFY appmgAr
D. STREET ADDRESS 47 New Hackensack Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r'!! NO
3. A. AGE 29 3B. DATE OF BIRTH MON9) / DRO / y~~81
4. EMPLOYMENT
A. USUAL OCCUPATION Resident~1 Dnnrm~n
B. TYPE OF INDUSTRY OR BUSINESS Healthcare
5. PLACE OF BIRTH Rrnmc New York
(CITY, STAT~ / COUNTRY IF NOT USA)
6. FATHER
A. NAME II llio Lllis Pesante
B. COUNTRY OF BIRTH Puerto Rico
7. MOTHER
A. MAIDEN NAME Margarita Sanche7
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
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE r,rAAn-PA~antA
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 073-66-3508
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY [Y' TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D. STREET ADDRESS 47 New Hackensack Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
/19 /1982
DAY YEAR
13. A. AGE ?R
13B.DATE OF BIRTH
01
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Social Worker
B. TYPE OF INDUSTRY OR BUSINESS Non-Profit
15. PLACE OF BIRTH Bronx, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME .Johnny Lee Green
. B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Susan Marie LaSpina
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
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 (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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the best of my k
as to my right to enter into the mar rage state.
,
21. SIGNATURE OF GROOM ~
USE
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 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
n
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
wledge and belief that the information I provided i
o 0
o 0
o 0
o 0
e that no legal impediment exists
08/27/201 0
DATE
by New York Domestic
~
{ SEAL }
~
NAME (PRINT)
MONTH
YEAR
TIME
MONTH
YEAR
SIGNATURE ~
MAILlNQ ADDR
2uMi
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
03: 15:>M
2010
10
26 2010
08
28
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTYJ)tI TC.i-J c 5S
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
)4 CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY 'tJ,UCI-IKt:EAsI C
~R LAO( "~MT, ~/lA!!P1ez.. (y-Ji.{If!!C).
-
SIGNATURE~