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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~~ 1368 .
~~~I:~~R 70
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
'i'i;:lnilln VII
MIDDl:.e' CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
VIlA I i:::mg
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
Q.
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE)
D. SOCIAL SECURITY NUMBER n 1 n-? 1-4717
2. RESIDENCE A NV B. nllt('hp~~
(STATE) (couNi'Yi
C. CHECK ONE 0 CITY IlJ TOWN 0 VILLAGE
~~~CIFY Fi~hkill
D. STREET ADDRESS 5 Van Horn Circle. Apt. F ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INODRPORATED VILLAGE? 0 YES ~ NO
3. A AGE 31 3B. DATE OF BIRTH Oq / ~O / HI?fi
MONTH OA Y YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 616-21-3171
12. RESIDENCEA.NV B.nlltr.hA~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Fishkill
D. STREET ADDRESs5 Van Horn Circle. Apt. F
ZIP 12508
o YES~ NO
1-977
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INODRPORA TED VILLAGE?
13. A. AGE ~O 3B. DATE OF BIRTH 07 AR
MONTH DAY
4. EMPLOYMENT
A USUAL OCCUPATION FnginAAr
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
5. PLACE OF BIRTH PUQi Citv Hubei Province. China
(CITY, STATE / 'COUNTRY IF NOT USA)
6. FATHER
A. NAME XinwLJ Vu
B. COUNTRY OF BIRTH China
7. MOTHER
A. MAIDEN NAME Shuizhen Gong
B. COUNTRY OF BIRTH China
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNUUMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
15. PLACE OF BIRTH Taiyuan City. Shanxi Province. China
(CITY, STATE / COUNTRY IF NOT USA) I
16. FATHER
A. NAME Zezhi Liang
'B. COUNTRY OF BIRT~hina
17. MOTHER
A. MAIDEN NAME Yulan Zhao
B. COUNTRY OF B1RTHChina
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 (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
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY/COUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. -~ YEAR
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) (CITYICOUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH, 0 0 4TH 0 0
I duly swear/affirm. depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marriage state.
21. SIGNATURE OF GROOM ~ 22. SIG TURE OF BRIDE ~ '1l~
USE CUR ~E CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This liCense authorizes the marriage in New York State of
Relations Law ~11 to perform marriage ceremonies within New York te. 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
h C. Masterson
07/18/2007
DATE
by New York Domestic
'~
} NAME (PRINT)
{SEAL SIGNATURE
'-v-I MA~5G
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
TIME
MONTH
YEAR
MONTH
YEAR
01:18:~ 07
19
2007
09
16 2007
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF Ii4WN OF 0 VILLAGE OF
SPECIFY LGbf r III. t e r
~L
L-IU
SIGNATURE~
DOH-9B (0312006)
SIGNATURE~