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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
. R~btE I 'Sam An~~l?ebT SURNAME
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and s
as to my right to enter into the
21. SIGNATURE OF GROOM"
USE CUR
23. SUBSCRIBED AND SWORN O/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 only for the purpose of a second or subsequent ceremon .
24. TOWN OR CITY CLERK 25. A SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) Jo C. MastersOn .
"J TIME MONTH
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c: 1368 .
~5~I~J~R 1 06
1. A. FULL NAME
FIRST
ll..
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 051-72-5373
2. RESIDENCE A. NY B. nlltchp~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY eJ TOWN 0 VILLAGE
AND P hk .
SPECIFY 01 Jg P.P.pSIP.
D STREET ADDRESS 331 Sheafe Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 24 3B. DATE OF BIRTH ()LI. / O? / H~R5
MOi:li'H DAY Y""R
l-
S;
e(
C
wU:
~u.
de(
4. EMPLOYMENT
A USUAL OCCUPATION RIJ~inp~~ ()wnpr
B. TYPE OF INDUSTRY OR BUSINESS Roma Deli
5. PLACE OF BIRTH Winter Garden, FI
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A NAME I~::lm l\IIir.h;:)pl Ann;:)hi
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Ikhlas Nesheiwat
B. COUNTRY OF BIRTH Jordan
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Amy Sar~s
MIDDLE CURRENT SURNAME
.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Ann::lhi
(OPTIONAL - SEE REVERSE) .
D. SOCIAL SECURITY NUMBER 371-08-9756
12. RESIDENCE A.I\III B. Wavne
(STATE) (cOUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Canton
D STREET ADDREss554 Shana St
ZIP48187
DYES tJ NO
A989
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 19 3B. DATE OF BIRTH 10 /'f 4
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Retail
B. TYPE OF IN~USTRY OR BUSINESS Retail
15. PLACE OF BIRTH Flint. MI
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. .NAME Imad Mousa Saras.
'B. COUNT~Y OF BIRTHPalestine
17. MOTHER
A. MAIDEN NAME Miranda Judeh Kassis.
B. COUNTRY OF BIRTHPalestine
lB. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(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
~
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
o
o
1ST
2ND
3RD
o 0
o 0
o 0
o 0
hat no legal impediment exists
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Ii;
SIGNATURE ~ DATE 09/11/2009
MAILING ADDRESS
20 Middle in ers Falls NY 12590
STREET ITYIT WN STATE ZIP
~~~R~:RTr~J IO~O~~~N~ZEE~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR rNif, RELIGIOUS
DATE AND AT THE TIME AND _ / "r
PLACE INDICATED. " GO PM /0 L( 0 9 0 OTHER, SPECIFY
~~S:~~~~~T~R tJ I "--l:fVL-I4c:; ({~T14 ~TITLE Pe-l '2.. S ~
SIGNATURE~___~ p~ DATE io/t..(f Or
MAILlNG/~~ '3 G'~~. Pole., )J,'1,
STREET STATE I
30. WITNESS TO CERE
~
{ SEAL }
'-v-'
NAME (PRINT)
SIGNATURE~
22. SIGNATURE OF BRIDE"
~
by New York Domestic
11 :26AM
PM
YEAR
MONTH
YEAR
09
12
2009
11
10 2009
10 CIVIL
26. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY QvTC-- ","--SS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
'f CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY ~c>u C:r-~ 1C..Jl,fl-.f'~( ~
~ ,\\,,\ c....'o\
SIGNATURE~