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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Timothy James Terralavoro
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~J~~~T1368
~5~~J~R 159
1 . A. FULL NAME
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)125_66_8607
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE) J-. (COUNTY)
C. CHECK ONE 0 CITY 0 TOWNU VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 22 Garden 51. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r:i YES 0 NO
04 /22 /1966
MONTH DAY YEAR
3. A. AGE 44
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Head Groundskeeper
B. TYPE OF INDUSTRY OR BUSINESS Arlington School Dist.
5. PLACE OF BIRTH Poughkeepsie, NY
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Thomas Francis Terralavoro
B. COUNTRY OF BIRTH U 5 A
7. MOTHER
A. MAIDEN NAME Gail Helen Palmateer
B. COUNTRY OF BIRTH U 5 A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEer
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
2ND
3RD
4TH
I duly swear/affirm, aep'ose a~aYI~tto the b
as to my right to enter into th[ m;.tl e ate.
21. SIGNATURE OF GROOM ~ .....
I
STATE FILE NUMBER
(TH/S SPACE FOR STA TE USE ONL Y)
'I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Cora Opelinia Resurreccion
MIDDLE CURRENT SURNAME
-.l
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE T erralavoro
(OPTIONAL - SEE REVERSElXXXXXXXXX
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A, NY B. Dutchess
(STATE) "'- (COUNTY)
C. CHECK Ot'li . [J CITY Q. TQWN 0 VILLAGE
~~~CIFY wappmgers t-alls
D. STREET ADDRESS~~ Garden ::;t.
12090
z~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIUAGE? 0 YE~.kl80NO
13.A. AGE 29 13BDATEOFBIRTH 12 ))4 ~
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Unemployed
B. TYPE OF INDUW'RY 9~ BUSINE~ Unem ployed
15. PLACE OF BIRTH t::SUKlanon, t-'tilllpplnes
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Herminio Candido Resurreccion
'B. COUNTRY OF BIRTHPhlllppmes
17. MOTHER ,
A. MAIDEN NAME Concepcion Pabatao Opelinla
B. COUNTRY OF BIRTHPhlllppmes
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D100RCE CIVIL ANBULMENT
D~TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
-' YEAR
MONTH DAY
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
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
w
en
z
w
o
::i
29. OFFICIANT
NAME (PRINT)
SIGNATURE~
DOH-98 (09/2009)
'Ro<;,v 0 \ ('I
__c~____
.~._... ........,-
SEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Yo State of the bride and groom named above by any person authorized
Relations Law ~11 to perlorm 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 CITYJ C~ERKC M t 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) onn . as erson
{ SEAL SIGNATURE~. DATE 11/18/201 YEAR
'-..,-I MAI~MPCJffi~ sh Rd, Wappingers Falls, NY 12590 2010
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
NAME 11/18/2010
DATE
by New York Domestic
MONTH
YEAR
01
17 2011
1 Jr CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~ll{1k/~~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF 0 VILLAGE OF
SPECIFY -t<:3 t1./I '; 7L) l' /"
c::
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