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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MID~~zim ZUk~RRENTSURNAME
USE CURR NT
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 t groom named above by any person authorized by New York Domestic
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
NAME (PRINT) Jo C. Maste
COUNTY Dutchess
CITYffOWN Wappin~er
~~~~kc~ 1368 .
~~~I:;~R 4
1. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A New York
(STATE)
C. CHECK ONE 0 CITY 0 TOWN ~
~~~CIFY Wappingers Falls
D. STREET ADDRESS 10 Colonial Drive, Apt. 6 E ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? cf YES 0 NO
3. A. AGE ?7 3B. DATE OF BIRTH
B. Dutchess
(COUNTY)
VILLAGE
4. EMPLOYMENT
A. USUAL OCCUPATION Cook
B. TYPE OF INDUSTRY OR BUSINESS Goodfellas Restaurant
5. PLACE OF BIRTH Isniq. Kosovo
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Sadik Zukaj
B. COUNTRY OF BIRTH Kosovo
7. MOTHER
A. MAIDEN NAME Aferdita Nurai
B. COUNTRY OF BIRTH Kosovo
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
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, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
o
o
o
w
UJ
Z
W
o
::i
~
{ SEAL }
'-y-I
SIGNATURE ~
MAILING ADDRESS
20 Middle
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
"'"
__,~ -LL.. 'L-- "
I
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Givla Gashi
MIDDLE CURRENT SURNAME
~
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Zukaj
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12 RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN cY' VILLAGE
~~~CIFY Wappinqers Falls
D. STREET ADDRESS 10 Colonial Drive Apt. 6 E ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? dYES 0 NO
04 /15 /1981
MONTH DAY YEAR
13. A. AGE 25
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Domestic Engineer
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Krvshec. Kosovo
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Magiun Gashi
'B. COUNTRY OF BIRTH Kosovo
17. MOTHER
A. MAIDEN NAME Beqije Bairamaj
B. COUNTRY OF BIRTH Kosovo
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
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
~
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
1ST 0 0
2ND 0 0
3RD 0 0
~ 0 0
he infqt'STlation I provided is true and that I declare that no legal impedimetrtl~,
22.SIGNA REOFBRIDE~ G'" it: GJ1SIl/~ ~/'
USE CURRENT NAME
TIME
YEAR
MONTH
YEAR
MONTH
09:021.M
PM
01
25
2007
03
25 2007
i~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN~I~ \ ((~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
SIGNATURE~
I
Gi c;. ,4 ,
~
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