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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Paulo Cesar Vallejo Arroyo
FIRST MIDDLE CURRENT SURNAME
CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
COUNTY Dutchess
CITYfTOWN Wappinger
DISTRICT1368
NUMBER
REGISTER162
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Heidi Star Marturano
..J
11. A. FULL NAME
FIRST
MIDDLE
0-
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Vallejo
(OPTIONAL - SEE REVERSE)1 03-72-3531
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY B. Dutchess
(STATE) "'- (COUNTY)
C. CHECK ONE 0 CITY U TOWN 0 VILLAGE
~~~CIFY Beekman
D. STREETADDRESlb fJleasent Kldge Kd ZIP lLb~U
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YE~ .Q86NO
13. A. AGE 24 13B.DATE OF BIRTH 11 )t6 ~
MONTH DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)133_88_8900
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. CT B. Litchfield
(STATE) J.... (COUNTY)
C. CHECK ONE 0 CITY'U TOWN 0 VILLAGE
~~~CIFY New Milford
D. STREET ADDRESS 45 Bank St: Apt 5 ZIP 06776
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
07 /02 /1984
DAY YEAR
3. A. AGE26
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION CleaninQ Service
B. TYPE OF INDUSTRY OR BUSINESS Janitorial
5. PLACE OF BIRTH Quito, Ecuador
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Cesar Jacinto Vallejo
B. COUNTRY OF BIRTH Ecuador
7. MOTHER
A. MAIDEN NAME Lourdes Ines Arroyo
B. COUNTRY OF BIRTH Ecuador
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Dental Assistant
B. TYPE OF INDU,WRY OR BUSI~EiSS DentIst
15. PLACE OF BIRTH uueens, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Carmine Marturano
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Thelma Patrinos
B. COUNTRY OF BIRTHU S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIOORCE CIVIL A~ULMENT
DEATH
o
D~TH
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
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
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
1ST 0 0 1ST
2ND 0 0 2ND
3AD 0 0 3AD
~ 0 0 ~
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provide
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM~ 7~ ~"' 22. SIGNATURE OF BRIDE~ .
USE C I
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
Aelations 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 CIl)' CI-ERKC M t 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) JOnn . as erson
{ SEAL } SIGNATURE~ ""(Jl: r;~ DATE 12/06/2010
'-v-I MA~tf~m~~Rd, Wappingers Falls, NY 12590 01:39;~ 12
STREET CITYITOWN STATE ZIP
~~~R~!~R;~J 'o~O~~~N~~E~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~L1GIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. 3;30 \ d. 1~ 1.0 9 0 OTHER, SPECIFY
W~LLW~
o
o
o
by New York Domestic
TIME
YEAR
MONTH
YEAR
MONTH
07
2010
02
04 2011
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY D Oie t\lS S
TITLE
v'\I\rl\l:t: S,TLR
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY 1\~wL:I:..N&
STREET CITYrrOWN
00. WIT",,, '_ .
NAME (PRINT) t\1l: ~~
SIGNATURE~