157
COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT1365 .
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REGISTER 1 5 (
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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jose Miguel Bernabe Lopez
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Yi
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Araceli Cristina Reyes Ojeda
FIRST MIDDLE CURRENT SURNAME
.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)050-90-3826
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) .L (COUNTY)
C. CHECK O~i. 0 CITY Q. T~WN U VILLAGE
~~~CIFY vvapplngers rails
D. STREET ADDRESs25 west Acadamy ~t
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)XXXXXXXXX
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. CT B. Fairfield
(STYE) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Danbury
D. STREET ADDRESS 25 Padanaram Rd ZIP 06511
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tJ YES 0 NO
02 /01 /1984
DAY YEAR
ZIP 12b9U
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 24 13B. DATE OF BIRTH 04 "l2
MONTH
DAY
YES 0 NO
)'986
YEAR
3. A. AGE 26
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY O,R BUSINESS Oakwood Friends School
15. PLACE OF BIRTH La Clenega, Oaxaca
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Leoncio Reyes Arellanes
B. COUNTRY OF B1RT~exlco
17. MOTHER
A. MAIDEN NAME Inocencia Ojeda Celaya
B. COUNTRY OF BIRTHMeXlco
1
16. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A~ULMENT
to-
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it
4. EMPLOYMENT
A. USUAL OCCUPATION Cashier
B. TYPE OF INDUSTRY OR BUSINESS La Mexlcana
5. PLACE OF BIRTH La Cienega, Oaxaca
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Casto Bernabe Ojeda
B. COUNTRY OF BIRTH Mexico
7. MOTHER
A. MAIDEN NAME Maria Lopez Reyes
B. COUNTRY OF BIRTH Mexico
6. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANOULMENT
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
DE6TH
D11TH
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
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm. depose and say est of my knowledge and belief that the information I provided is true and that 1 declare that no legal impediment exists
as to my right to enter into the /1?
21. SIGNATURE OF GROOM~ 2. SIGNATURE OF BRIDE~ ~~ ~ {VI!:II~
23 SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ~~E CU USE U EN NAME 11/16/'2010
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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 cr~o'ft~'C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
SEAL SIGNATURE ~. DATE 11/16/2010 TIME MONTH
'-..t-I MA~rofImiM ush Rd, Wappingers Falls, NY 12590 12:41 ~~ 11 17 2010 01 15 2011
ZIP
YEAR
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
2' jHt
. CD PM {l
STATE
27. TYPE OF CEREMONY
o ~ELlGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~ ll'\C \..t ;. !;.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~\Jq "'-'c\e.e.'? s \ e.
29. OFFICIANT
NAME (PRINT'
DATE
N-
10
TITLE
e~~\i~ r~\es'-
/2-11-1'0
ll.bD
:JOSG A\tij"N1H~Q ~DIA"~PE:.
MAILING ADDRE~ <i) ,
- CKII(2..c H $r rOL'1~~t.~ ~s.le
STREET CITYfTOWN
30. WITNESS TO CEREMONY
NAME (PRINT) -1=~ (\""J"
SIGNATURE ~
STATE
SIGNATURE~
DOH-96 109/2009\
NAME (PRINT)
SIGNATURE~