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51 A IE OI:~eWBVORK :,>r-
DEPARTMENT'OF HEALTH .
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Efrain Geigel
FIRST MIDDLE CURRENT SURNAME
1ST _
mD 0
~ 3RD 0
u ~ 0
no'Niedge and belief that the information I provided is true and that I declare that no legal impediment exists
22 SIGNATL'RE OF BRIDE ~ 1"0. 1"'.~.f) U()~ I b ^
~UR;E~~AMt=f ~--
23 SUBSCRIBED AND SWORN TO BEFO Deputy Town Clerk DATE II _ L' - 00
SIGNATURE OF TOWN OR CITY CLER :::t :::l -
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 CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT)~ Elaine H. Snowden, Town Clerk
{SEAL SIGNATURE~(~ll1V~&.l,^.A'I- DATE 4/5/00 TIME MONTH DAY YEAR MONTH
MAILING ADDREliS AM 04 06 00 06 04
~ PO Box J24 Wa in ers Falls, NY 12590 2:30PM
ST EET CI WN A Zl
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. 7PE OF CEREMONY
~~~SM~~~~~~B~V;~N P~RE IME MO. DAY Y R 0 rL RELIGIOUS 1 C CIVIL
g~~E ~~gIC"}T~~E TIME AND .3 : IJ = 0 if - I) Y - c () 9 C OTHER. SPECIFY
COUNTY
8WrOWN
DISTRICT
NUMBER
REGISTER
NUMBER
Dutchess
Wappinger
1368
32
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
1. A. FULL NAME
0-
N
B BIRTH NAME. IF DIFFERENT
/~,~\OV
L
~
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 058 -66 - 7911
D SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
(STA!5/: (COUNTY)
C. CHECK ONE _ CITY 0 TOWN 0 VILLAGE
~~~CIFY poughke ~~ s ie
D. STREETADDRESS 99 Livingston St. 50lzlP 12601
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE? :lEJ
/17
DAY
3. A. AGE 1 9
Oct.
MONTH
YES C NO
/1980
YEAR
o SUPPLEMENTAL FILE
FROM THE BRIDE
Nakia D. Holman
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
3B. DATE OF BIRTH
4. EMPLOYMENT
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~
A. USUAL OCCUPATION US Coas t Gaurd
B. TYPE OF INDUSTRY OR BUSINESS . Seaman Apprentice _
Bronx New York
(CITY. STATE/COUNTRY IF NOT USA)
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SDCIAl SECURITY NUMBER
12. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONEp ~_ ..cITY ll. lOWN 0 VILLAGE
AND ougnKeep~1e
SPECIFY
D. STREET ADDRESS 48 Corlies Ave. NY ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? ~ YES 0 NO
13. A. AGE lR 13.B.DATEOFBIRTH March /29 /1982
MONTH DAY YEAR
Geigel
112-68-3572
14. EMPLOYMENT
A. USUAL OCCUPATION
Unemployed.Student
5. PLACE OF BIRTH
6. FATHER
A. NAME
Efrain Gonzalez
Puerto Rico
IL TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH District of Columbia
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Earl Pastiant
B. COUNTRY OF BIRTH Unknown
17. MOTHER
A. MAIDEN NAME Kim Holman
B. COUNTRY OF BIRTH TTSA
lB. NUMBER OF THIS MARRIAGE
1;';-rc:r
B. COUNT'lY OF BIRTH
7. MOTHER
A. MAIDEN NAME -
B. COUNTRY OF BIRTH
_M.~:t;i.lda Geigel
Puerto Rico
First
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (3) C DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) = DEA iH
B. HOW DID LAST MARRIAGE END? (3) C DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) C DEATH
31 ::J ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSEiS) ALIVE? = YES = NO
20. 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
YEAR
00
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY .JJ1lr/'~
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~TY OF 0 .OWN OF 0 VILLAGE ~ "
SP<WY /b;r::4W ~:9;
MCNTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, tha
as to my right to enter into the mar( at
u
21. SIGNATURE OF GROOM~
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en
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29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
~~,(HIll8I
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