053
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT B8! DEATH
C. DATE LAST MARRIAGE ENDED? 04 / 03 / 2 9 '
MONT~ DAY
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) (CITYICOUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST 04/03/2009 Poughkeepsie, New York 0 ~ 1ST
2ND 0 0 2ND
3RD 0 0 3RD
4TH 0 0 4TH
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true
as to my right to enter into the marnage state. .
21. SIGNATURE OF GROOM~ . SIGNATURE OF BRIDE~
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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Omar M AI-Shloul
COUNTY Dutchess
CITYffOWN Wappinger
~~J~~c; 1368
~5~I~J~R 53
1. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
8. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl098_92_4655
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(ST A TEl (COUNTY)
C. CHECK ONE 0 CITY'6 TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 93 Violet Ave
ZIP 12tiU 1
"'-
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
01 /18 /1973
DAY YEAR
3. A. AGE 36
3B. DATE OF BIRTH
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION Self Em~oyed
B. TYPE OF INDUSTRY OR BUSINESS etail
5. PLACE OF BIRTH Douqara, Jordan
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Mahmoud AI-Shloul
B. COUNTRY OF BIRTH. Jordan
7. MOTHER
A. MAIDEN NAME Radwah Mohammad
B. COUNTRY OF BIRTH Jordan
8. NUMBER OF THIS MARRIAGE 2
DEATH
o
YEAR
(TH/S SPACE FOR STATE USE ONLY)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Anise Xochitl Cruzado
-.J
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE AI-Shloul
(OPTIONAL. SEE REVERSE057 -7 4-2796
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A.NY BDutchess
(STATE).L (COUNTY)
C. CHECK Otll' liD CITY U TOWN 0 VILLAGE
~~~CIFYt-'oug lKeepsle
IBb Main Street 12603
D. STREET ADDRESS ZIP
..,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATiD VILLAGE? ?O 0 YEJ );l,~O
13. A. AGE36 3B. DATE OF BIRTH 1 c E
MONTH DAY YEAR
14. EMPLOYMENT .
A. USUAL OCCUPATION Master Pedlcurest
Gosmetology
B. TYPE OF IND4aTRY OR B~$INESS. . . .'
I:Sronx New YOrK .
15. PLACE OF BIRTH '
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Daniel Alberto Cruzado
'B. COUNTRY OF BIRTHU ~ A
17. MOTHER D' T
A. MAIDEN NAME lana orres
B. COUNTRY OF BIRTHU ~ ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A"eULMENT
D'{tTH
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
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
YEAR
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN;J).~~Y:..&
C. LOCATION OF CEREMONY
(CHECK ONE ANYSPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
USE CURR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
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 Clj CLERK 25. A. SOLEMNIZATION PERIOD BEGINS'
{ } NAME (PRINT)
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
I.- -.J MAI~~~p~ AM 06 05 2009 08 03 2009
-v- 02:11 PM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
SPECIFY 9~ ~7't:;: A"LA1
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) , ' ~ .-5'7 q
~
SIGNATURE~ (
~ \~C\\
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