140
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
I
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Shawn Elmer Razzaque
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
DISTRIC!1368 '
NUMBER
REGISTEA140
NUMBER
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Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
Clare Marie Cornett
11, A. FULL NAME
1. A. FULL NAME
CURRENT SURNAME
MIDDLE
FIRST
FIRST
B. BIRTH NAME (MAIDEN NAME~ DIFFERENT
C. SURNAME AFTER MARRIAGE azzaq ue6
(OPTIONAL - SEE REVEASl(lJb4- { L - { ~ 4
D. SOCIAL ~QJRITY ~UMBE~ Ll'"
Marylana nowaru
12. RESIDENCE A. B.
(SV':E) (COUNTY)
C. CHECK OtolE I [;], CITY 0 TOWN 0 VILLAGE
AND \",,0 umOla
SPECIFY 0363 Hell vt::~L MUUII Ldlle
D. STREET ADDRESS
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B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE879-02-0754
D. SOCiAl SECURITY NUMBER
2. RESIDENCEA.MARYLAND B. Howard
(S~TE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN 0 VilLAGE
AND C I b'
SPECIFY 0 um la .
D. STREET ADDRESS 5383 Harvest Moon Lane
+
21044
U
o Y~EfO
YEAR
21044
ZIP
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E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0
02 /28
DAY
E. IS R~I~ENCE WITHIN LIMITS OF CITY OR INCORPO~ VILLAGEj>1
13. A. AGr!: 3B. DATE OF BIRTH
MONTH DAY
14. EMPLOYMENT S ft E'
o ware nglneer
A. USUAL OCCUPATION Ddellct:: CUI ILl i:Idul
B. TYPE OF INDI.I$TRy.ooa\J.sgs..s N ., k
I""'OU~IIKet::1-I5Ie, ew T UI
15. PLACE OF BIRTH
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER .
KeVin Barry Cornett
A.NAME USA
B. COUNTRY OF BIRTH
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YEAR
3. A. AGE23
3B. DATE OF BiRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Auditor
B. TYPE OF INDUSTRY OR BUSINES~Accountlng
5. PLACE OF BIRTH Wayne, Mic Igan
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Mohammed Abdur Razzaque
B. COUNTRY OF BIRTH Bangladlsh
7. MOTHER
A. MAIDEN NAME Diane Helen Peterson
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
17. MOTHER Kathleen Marie Healy
A. MAIDEN NAME USA
B. COUNTRY OF BIRTH 1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DffORCE CIVIL A'l5"ULMENT
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
D~TH
D'tl TH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. -- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
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20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEAJH
C. DATE LAST MARRIAGE ENDED? / /
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) (CITYICOUNTv, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
1ST 0 0 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare
as to my right to enter Into the mamage state.
21. SIGNATURE OF GROOM~ 22. SIGNATURE OF BRIDE~
USE CURRENT NAME 12/11/2009
DATE
by New York Domestic
USEC R
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
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
n
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{ } NAME (PRINT)
SEAL SIGNATURE ~ "
'-t-I MAI~~ ItRP e
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTYDu+",he~s
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
. or,!. ",' Y uF ){ TOWN OF 0 VILLAGE OF
SPECIFY---=B ~a..-CO~T fi S~\('l U
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STREET
30. WITNESS TO CEREMONY
NAME(PRINT) STG.V~N f:. ~,I\2:ZA&v6
SIGNATURE~ ~~ l!!:; ~
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