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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
B~i~11 P.1.11 I aftblRENT SURNAME
COUNTY DlltchA~S
CITYrrOWN \N;:!rrinOAr
~~~:~CRT 13RR
~~~I~J~R ~?
1 . ,A. FUll NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 11 0-66-1 088
2. RESIDENCE A. NYSTATE) B '-+J~
C CHECK ONE 0 CITY J[I TOWN 0 VILLAGE
AND
SPECIFY EiopU5I
D STREET ADDRESS 1746 ROlltA q\N ZIP 1 ?493
E. IS RESiDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES olJ NO
3. A AGE 28 3B DATE OF BIRTH M~~ / QP / ;k~79
4. EMPLOYMENT
A. USUAL OCCUPATION Service Engineer
B. TYPE OF INDUSTRY OR BUSINESS Medical
5. PLACE OF BIRTH ~i.Q~lr,.~~Rb~X IF NOT USA)
6. FATHER
A. NAME Paul Fr::mcis Jaffer
B. COUNTRY OF BIRTH IJ 5 A
7. MOTHER
A. MAIDEN NAME Helen Marg.ret Born
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
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
I A;:Jnn;:J M;:JriA [")rahos
MIDDLE CURRENT SURNAME
-.J
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Jaffer
(OPTIONAL - SEE REVERSe)
D SOCIAL SECURITY NUMBER 061-64-4725
12 RESIDENCE A, NY B IIl!';tAr
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0 TOWN 0 VILLAGE
AND
SPECIFY E!';npIJS
D. STREET ADDRESS 1746 Route 9w
ZIP 12493
o YES~ NO
/lqRn
YEAR
E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
38. DATE OF BIR;H n? /? 1
MONTH DAY
13. A. AGE 28
14. EMPLOYMENT
A. USUAL OCCUPATION R;:!r1inlnoy S'r.hArll liAr
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTH Nnrth T;:)rrvtown NY
(CITY, STATE I COUrrrRY IF NOT USA)
16, FATHER
A. NAME Not Listed
'8. COUNTRY OF BIRTHNnt listed
17. MOTHER
A. MAIDEN NAME R;:Jrh;:Jr;:) Ann nrahos
B. COUNTRY OF BIRTH I J S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
n
o
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
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 1ST
o 0 2ND
o 0 3RD
o 0 4TH
est of my knowledge and belief that the information I provided is tr. e
o 0
o 0
o 0
o 0
gal impediment exists
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New Y State of he bride and groom named above by any person authorized
RelatiDns 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
21. SIGNATURE OF GROOM
~
{ SEAL }
'-.-'
NAME (PRINT)
DATE
22, SIGNATURE OF BRIDE~
DATE
n4/1 R/?nnR
by New York Domestic
TIME
MONTH
YEAR
MONTH
YEAR
AM
06:00PM
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B, COUNTY i}/ ~1.t' ~)r
.
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR 0 0 RELIGIOUS
20 O'i 90 OTHER, SPECIFY
04
17
2008
06
15 2008
1 V"CIVIL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
29. OFFICIANT
NAME (PRINT)
TITLE ~ t ~~}t IL.
DATE 4 --20- 0'8
li1 i 111.Jt '(-vi,
L'v~
SIGNATURE ~
MAILING ADORE
NAME (PRINT)
SIGNATURE~
SPECIFY
STATE
NAME (PRINT)
SIGNATURE~