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COUNTY Dutchess
CITYfTOWN Wappinger
~~~:kc: 1368 '
~~~~J~R 178
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brian J. Dexter
MIDDLE CURRENT SURNAME
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
~
1 , A, FULL NAME
FROM THE BRIDE
Sherry Yao Yi Cheng
FIRST MIDDLE CURRENT SURNAME
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT Yao Yi Cheng
c. SURNAME AFTER MARRIAGE Chenq-Dexter
(OPTIONAL - SEE REVERSE) 619-40-1571
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY c( TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 201 Van Mackey Drive
11. A. FULL NAME
FIRST
"-
N
B. BIRTH NAME, IF DIFFERENT
C, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 063 60 2124
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r!f TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 201 Van Mackey Drive
ZIP 12590
YES ri NO
/1978
YEAR
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
09 / 10 / 1976
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
10 /03
MONTH DAY
13. A. AGE 28
3. A. AGE 30
3B. DATE OF BiRTH
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Acupuncturist
B. TYPE OF INDUSTRY OR BUSINESS Health Care
5. PLACE OF BIRTH Buffalo, New York
(CITY, STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Business Analyst
B. TYPE OF INDUSTRY OR BUSINESS Finance
15. PLACE OF BIRTH Taipei City, Taiwan
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Wen Chiung Cheng
'B. COUNTRY OF BIRTH Taiwan
17. MOTHER
A. MAIDEN NAME Jey Shing Meng
B. COUNTRY OF BIRTH Taiwan
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
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c:(
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c:(
6. FATHER
A. NAME Frank Dexter
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Marylou Ann Martin
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 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
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. ',- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOLlSE(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, STATElCDUNTRY, IF NOT USA) SELF SPOUSE
(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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
o
o
o
Ia
ent exists
1ST
2ND
3RD
w
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(.)
:::::;
1ST
2ND
3RD
4TH
I duly swear/affirm, deP.OSe and say, that to the best of my
as to my right to enter into the ma ge state.
21. SIGNATURE OF GROOM~ r
USE CU
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York 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 pu sa of a second or subsequent ceremony.
~ 24. TOWN OR CITY CL,ERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jonn C. Masterson
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ -
'- -..J MAI~ too!fd~ AM 11 16 2006 01 14 2007
-yo- 06:48pM
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDI
YEAR
ZIP
l~L
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~ w.Tt.tf-l.4j
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFY vJ Atilt', M...Wo\ ~
SIGNATURE~