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COUNTY Dutchess
CITYffOWN Wappinger
~~~~kc; 1 368
~~~I~~~R 9
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bain Kuriakose
MIDDLE CURRENT SURNAME
:)01 AI I:. rll..t:: ....UMI:n:.t1
(THIS SPACE FOR STATE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Raina Eve Levy
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A FULL NAME
FIRST
FIRST
..
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D. SOCIAL SECURITY NUMBER XXX-XX-XXXX
2 RESIDENCE A. NY B. Dutchess
(STAlE) (COUNTY)
C. CHECK ONE "D CITY 0 TOWN 0 VILLAGE
~~~CIFY Pouqhkeepsie
D. STREET ADDRESS 110 Mill Street, Apt 1 a ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tJ YES 0 NO
05 /14 /1973
MONTH DAY YEAR
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSEl126_54_8646
D. SOCIAL SECURITY NUMBER
12 RESIDENCE ANY BDutchess
(ST~JoE) (COUNTY)
C. CHECK ONE'[] CITY 0 TOWN 0 VILLAGE
AND P hk '
SPECIFY oug eepsle
D. STREET ADDRESS 110 Mill Street, Apt 1 a ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
~8 )t'970
DAY YEAR
08
13. A. AGE 38
3. A AGE 35
3B, DATE OF BIRTH
3B. DATE OF BIRTH
MONTH
4, EMPLOYMENT
A. USUAL OCCUPATION Chef
B. TYPE OF INDUSTRY OR BUSINESS Food & Beverage
5. PLACE OF BIRTH Neerkuzhi, Kerala, India
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Kuriakose Manthanath
B. COUNTRY OF BIRTH India
7, MOTHER
A. MAIDEN NAME Leela Ulahannan
B. COUNTRY OF BIRTH India
B. NUMBER OF THIS MARRIAGE 1
9, PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Recreational Specialist
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH Brooklyn, New York
(CITY, STATE / COUNTRY IF NOT USA)
16, FATHER
A. NAME Allan Donald Levy
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Sharon Fox
B. COUNTRY OF BIRTHU S A
1 B. 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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
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
MONTH DAY YEAR
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 0
o 0
o 0
o 0
no legal impediment exists
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and S
as to my right to enter into the ma
21, SIGNATURE OF GROOM.... ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
I that to the best of my knowledge and belief that the information I provided Is ~e~d tha
age state. ( './
" 22. SIGNATURE OF BRIDE~ j' c..;1tl.-
U
23. SUBSCRIBED AND SWORN TO/AFFIR ED BEFORE M:E ~
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in New Y ~rk 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) Jo n C. Masterson
{SEAL SIGNATURE" ! (' ,t,--- " DATE 03/09/2009 TIME MONTH YEAR MONTH
MAILING ADDRESS , AM 09
'-v-I 20 Middle ush Rd. Wappinqers Falls. NY 12590 12:01 PM 03 10 2009 05 08 20
STREET CITYfTOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO, DA YEAR 0 0 RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
03/09/2009
YEAR
2B. PLACE WHERE MARRIAGE OCCURR.E E?J
A. STATE NEW YORK B. COUN~ TE ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY l,j4PP F1df?~ !lC'~
NAME (PRINT)
SIGNATURE"
DOH.98 (03/2006)
.t Z:::,"1 0
ZIP
31. WITNESS TO CEREMONY
I-C 1.... 0 C' ,
NAME (PRINT)
SIGNATURE"