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1. A. FULL NAME
STATE OF.;NEWYORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Gerardo Jose
FIRST MIDDLE
l
STATE FILE NUMBER
. (THIS SPACE FOR STATE USE ON/. Y)
I
Dutchess
Wappinger
1368
34
Jo7>
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Yesica Fernanda
FIRST MIDDLE
~
Abril
Buele
11. A. FULL NAME
CURRENT SURNAME
CURRENT SURNAME
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE.\. New York
(STATE)
C. CHECK ONE 0 CITY 00 TOWN 0
AND
SPECIFY Wappinger
D. STREE"TADDRESS 3 Colonial Drive B-9
ZIP 12590
Anri 1
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York
(STATE)
o CITY iX TOWN 0
l.J;!pping~r
3 Colonial Drive
n/a
C. CHECK ONE
AND
SPECIFY
097-80-7702
B. Dutchess
(COUNTY)
VILLAGE
B. Dutchess
ICOUNTY)
VILLAGE
12590
B-9 ZIP
o STREET ADDRESS
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 28 3B. DATE OF BIRTH Aug. /
MOI'lTH
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES)f] NO
13.A.AGE 22 13.B.DATEOFBIRTH Feb. /11 A978
MONTH DAY YEAR
o YES~ NO
10 /1971
YEAR
DAY
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION Cleaning
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTH ~an BIas. Can ton Cuenca, Ecuador
(CITY, STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION Housekeeping
B. TYPE OF INDUSTRY OR BUSINESS Tri Enterprise
5. PLACE OF BIRTH Victoria del Porte te, Ecuador
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME
Ivan Homero Abril
Ecuador
6. FATHER
A. NAME Jose Manuel Buele
B. COUNTRY OF BIRTH Ecuador
B. COUNTRY OF BIRTH
17. MOTHER
Mercy Coronel
Ecuador
First
7. MOTHER
A. MAIDEN NAME Antonia Felicia Abril Galvez
B. COUNTRY OF BIRTH Ecuador
8. NUMBER OF THIS MARRIAGE First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. MAIDEN NAME
B. COUNTRY OF BIRTH
1 B. NUMBER OF THIS MARRIAGE
19. PREVIOUS '-IARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B HOW DID LAST MARRIAGE END? (3) L: DIVORCE
.3) 0 ANNULMENT
/ /
(21 L: DEATH
B. HOW DID '..AST MARRIAGE END? (3) 0 DIVORCE
C. DATE ~AST MARRIAGE ENDED?
(3) = ANNULMENT
/ /
2) u DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE .ANY FORMER SPOUSE(S) ALIVE? 'J YES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE "CLLOWING INFORMATION
DATE :" JECREE PLACE ISSUED~GAINST WHOM
(MONTH. JAY. YEAR) (CITY, STATE/COUNTRY, IF NOT USA\ SELF SPOUSE
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? = YES ::::J NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY. STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I. being duly sworn, depose and
as to my right to enter into the
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22. SI,GNA TURE OF BRIDE ~ Yp ~ ~r ~ 4;-,1' ": /
USE CURREN"f'NAME
DATE April 7, 2000
by New York Domestic
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23. Deputy Town Clerk
This license authorize the marriage in New York ate 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 onl for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) c:;:, Ela1-~e ~ Snowden, Town Clerk TIME MONTH YEAR
SEAL SIGNATURE~~~ ~dJl_ DATE 4/7/00
MAILING ADDREll~ 10: OOAM
'-v-I PO Box jl4, Wappingers Falls, NY 12590 PM 4 8 00
STREET CITYIT WN STATE ZIP
~~~R~~Ri~~ 10~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27 TYPE OF CEREMONY
SONS NAMED ABOVE ON THE IME MO. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND AM
PLACE INDICATED. (i;: 0 PM .s- '" DC 9 u OTHER. SPECIFY
~AS:~~9i~~T~v tJJ-!-/I~M h' /~'Ar~>): TITLE
SIGNATURE ~
MAILING A DR S5
~
STR T CITYlTOWN
30. TNESS TO CEREMONY
NAME (PRINT~!!- HA )JPO !1 D 61Z0u r::J 0
....,
2.
6
6
00
MONTH
YEAR
, = :IVIL
28. PLACE WHERE MARRIAGE OCCURRED
..-0'1
A. STATE NEW YORK B COUNTY (...Itl. y(~
C. LOCATION OF CEREMONY J
(CHECK ONE AND SPECIFY)
[]"'CITY OF 0 TOWN OF = VILLAGE OF
SPECIFY tV;<L) ft~J
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) --J,., a. Eo
SIGNATURE~
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