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096 "- N + .... Z W Ul W '" C ..J ::>' o :I: Ul Z o ~ ti; a w a: w " < a: a: < ~ LL o ~ u u: ~ w u w a: w ~ Ul Ul w a: c c < ~ u W ll. Ul + Z' . ~E~ w tu~~ t;: a:~_ ....... ti;~ ~ (.) :')(,.)W _ ::i " c5 Li. !zZUl - ~~\51 ~ itOUl W ~~~ (.) w'" b~U) z::;;;; COUNTY Dutchess CITYfTOWN Wappinger ~~~:~RT 1 368 . ~5~I~J~R 96 STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM I ::Jnr.p. .Jn~p.rh R::Jrthnlnmp.w MIDDLE CURRENT SURNAME I STATE FILE NUMBER (THIS SPACE FOR STA TE USE ONL YI I L 0 SUPPLEMENTAL FILE FROM THE BRIDE Nina Marie Yeh MIDDLE CURRENT SURNAME ~ 1. A. FULL NAME 11. A. FUll NAME FIRST FIRST B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL. SEE REVERSE) 1 O' 9 74 4082 D. SOCIAL SECURITY NUMBER ~ __ - __ - ____ 2. RESIDENCE A. NY B. DLJtr.he~~ (STATE) (COUNTY) c. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE AND W . SPECIFY applnger D. STREET ADDRESS 17 Apt H White Gate Drive ZIP 12590 E. IS RESIDENCE WITHIN LIMITS OF CITY DR INCORPORATED VILLAGE? 0 YES'~ NO 3. A. AGE ?4 3B. DATE OF BIRTH O? / 16 /1985 MONTH DAY YEAR B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT C. SURNAME AFTER MARRIAGE Rarthnlomew (OPTIONAL. SEE REVERSE)067 74 9923 D. SOCIAL SECURITY NUMBER -- 12. RESIDENCE A. NY B. Dutchess (STATE) (COUNTY) C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE ~~~CIFY Wappinaer D. STREET ADDRESS 17 Apt H White Gate Drive ZIP 12590 DYES tJ NO /1'984 YEAR E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 13. A. AGE 25 3B. DATE OF BIRTH 02 /f 5 MONTH DAY 14. EMPLOYMENT A. USUAL OCgUPATION Consultant B. TYPE OF I~DUSTRY'OR BUSINESS F::"esi3 15. PLACE OF BIRTH Harford, MD (CITY, STATE / COUNTRY IF NOT USA) 4. EMPLOYMENT A. USUAL OCCUPATION Elevator Constructor B. TYPE OF INDUSTRY OR BUSINESS Construction 5. PLACE OF BIRTH Poughkeepsie, NY (CITY, STATE / COUNTRY IF NOT USA) 6. FATHER A. NAME' Denis Bartholomew B. COUNTRY OF BIRTH USA 7. MOTHER A. MAIDEN NAME Lori Jean Degelormo B. COUNTRY OF BIRTH U S A 8. NUMBER OF THIS MARRIAGE 1 9. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 16. FATHER A. NAME Nevin Yeh 'B. COUNTRY OF BIRTHU S A 17. MOTHER A. MAIDEN NAME Irma Juana Alicea B. COUNTRY OF BIRTHPuerto Rico 18. NUMBER OF THIS MARRIAGE 1 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 DEATH o DEATH o B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE C. DATE LAST MARRIAGE ENDED? (3) 0 ANNULMENT / / (2) 0 DEATH (3) 0 ANNULMENT (2) 0 DEATH / / MONTH DAY - YEAR D. AI;!E 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 B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE 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) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE o 0 o 0 o 0 o 0 ediment exists o 0 1ST o 0 2ND o 0 3RD o 0 4TH o edge and belief that the information I provided i w en z w (.) ::::i 1ST 2ND 3RD 4TH I duiy swear/affirm, depose and say, that t t~ be as to my right to enter into the ma~, ~ 21. SIGNATURE OF GROOM~ USE 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 only for the purpose of a second or subsequent ceremony, t-"'-. 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS { } NAME (PRINT) J TIME MONTH YEAR SEAL SIGNATURE ~ DATE 08/301. /2009 \...- .-J MAIUIiG f.r;}f)FjE 08 41 AM -v- LU IVI a in ers Falls, NY 12590 : 09 STREET CITY/TOWN STATE ZIP PM ~~~~:RT~~J IO~O~~~N~Z:~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY SONS NAMED ABOVE ON THE TIME MO. DAY YEAR oJ!!l. RELIGIOUS DATE AND AT THE TIME AND PLACE INDICATED. 9 0 OTHER, SPECIFY 10 .30 2009 by New York Domestic MONTH YEAR 01 2009 10 CIVIL 28. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNTY-:JJ..if~ C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF ,fa TOWN OF 0 VILLAGE OF SPECIFY A..a...- {}, ~ oR J NAME (PRINT) SIGNATURE~ NAME (PRINT) SIGNATURE~