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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Shahazhan Anthony Haque
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~ 1368
~~~:l~R 66
1. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 051-64-2122
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B Dutchess
(STAT.f) (COUNTY)
C. CHECK ONE !J CITY 0 TOWN 0 VILLAGE
~~CIFY Poughkeepsie
D. STREET ADDRESS 30 Noxon Street ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CllY OR INCORPORATED VILLAGE? d' YES 0 NO
3. A. AGE 38 3B. DATE OF BiRTH 07 / 30 / 1968
MONTH DAY YEAR
I
STATE FILE NUMBER
(TH/S SPACE FOR STATE USE ONL Y)
4. EMPLOYMENT
A. USUAL OCCUPATION Peace Officer
B. TYPE OF INDUSTRY OR BUSINESS Public Safety
5. PLACE OF BIRTH Manhattan, New York
(CITY, STATE / COUNTRY IF NOT USA)
...
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6. FATHER
A. NAME Mazharul Haque
B. COUNTRY OF BIRTH Pakistan
7. MOTHER
A. MAIDEN NAME Carole Ponds Ullah
B. COUNTRY OF BIRTH USA
1
8. NUMBER OF THIS MARRIAGE
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Paula Patricia Washburn
MIDDLE CURRENT SURNAME
..J
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO~CE CIVIL AN~LMENT
D~H
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE H aq ue
(OPTIONAL - SEE REVERSE) 096-70-7000
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B. Dutchess
(STAIj) (COUNTY)
C. CHECK ONE I!J CITY 0 TOWN 0 VILLAGE
AND P hk .
SPECIFY oug eepsle
D. STREET ADDRESS 30 Noxon Street ZIP 12601
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
13. A. AGE. 32 3B. DATE OF BIRTH 04 /10 /1'975
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Housewife
B. TYPE OF INDUSTRY OR B\JSI!'lFSS
15. PLACE OF BIRTH Carmel, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Paul R. Washburn, Sr.
'B. COUNTRY OF BIRTH U SA
17. MOTHER
A. MAIDEN NAME Patricia C. Gregory
B. COUNTRY OF BIRTH U S ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHII;:H ENDED BY
DI'tYRCE CIVIL AN~ULMENT
DE6TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEAJH
B. HOW 010 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
, ~..,.~- '"
2D. IF PREVIOUSLY DIVORCED OR ANNULL'ED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
Y knowledge and belief that the information I provided is t
23. SUBSCRIBED AND SWORN TOIAFARM D BE
SIGNATURE OF TOWN OR CITY CLERK
This license authorizes the marriage in New e bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies hin 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 seeond or subsequent ceremony.
24. TOWN OR CI1J8 ~KC. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
22. SIGNATURE OF BRIDE'-
(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. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
~
{ SEAL }
'-..,-I
TIME
YEAR
MONTH
YEAR
MONTH
AM
02:12pM
07
10
2007
09
07 2007
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
STATE ZIP
27. TYPE OF CEREMONY ....._/
00 RELIGIOUS ~CIVIL
9 0 OTHER, SPECIFY
29. OFFICIANT
NAME (PRINT)
SIGNATURE~
nn~_QA 1n~1?tv\R\
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEWYORK B.COUNTY~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY om TOWN OF 0 VILLAGE OF
SPECI~\ ~p,-
SIGNA RE~
/