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COUNTY Dutchess
CITYfTOWN Wappinger
~~J=kc: 1368 '
~5~~J~R 161
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael Fahed Hattar
MIDD~E CURRENT SURNAME
~I"IC I"'Ir-C nUMacn
(TH/S SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Helen Yole Miello
MIDD~E CURRENT SURNAME
-.J
1. A, FU~ NAME
11. A, FULL NAME
FIRST
FIRST
B, BIRTH NAME, IF DIFFERENT
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Miello
(OPTIONAL. SEE REVERSE) 126-66-2413
0, SOCIAL SECURITY NUMBER
12, RESIDENCE A. New York B, Orange
(STATE) .J. (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN!:J VILLAGE
~~~CIFY Cornwall-on-Hudson
0, STREET ADDRESS 23 Avenue A ZIP 12520
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? '6 YES 0 NO
13. A, AGE 35 3B, DATE OF BIRTH 07 /08 ;1'971
MONTH DAY YEAR
C, SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 125-62 2764
0, SOCIAL SECURITY NUMBER -
2, RESIDENCE A. New York B, Dutchess
(STATE) (COUNTY)
C, CHECK ONE 0 CITY~ TOWN 0 VILLAGE
~~CIFY Wappinger
0, STREET ADDRESS 3 Tor Road ZIP 12590
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
01 /14 /1966
MONTH DAY YEAR
3. A, AGE 40
4, EMPLOYMENT
A USUAL OCCUPATION Reoional Manaoer
B, TYPE OF INDUSTRY OR BUSINESS Nortrax
5. PLACE OF BIRTH Yonkers, New York
(CITY, STATE / COUNTRY IF NOT USA)
3B. DATE OF BiRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Sole proJ2rietor
B. TYPE OF INDUSTRY OR BUSINESS The UPS Store
15. PLACE OF BIRTH Brooklyn, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A, NAME Anthony J. Miello
'B, COUNTRY OF BIRTH USA
17, MOTHER
A MAIDEN NAME Yole Sigelakis
B. COUNTRY OF BIRTH USA
1
lB. NUMBER OF THIS MARRIAGE
6. FATHER
A. NAME Fahed Hattar
B. COUNTRY OF BIRTH Jordan
7. MOTHER
A, MAIDEN NAME Rifah Hattar
B. COUNTRY OF BIRTH Jordan
8, NUMBER OF THIS MARF,lIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI'OORCE CIVIL AN~ULMENT
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DE~TH
1 0 U
B. HOW DID LAST MARRIAGE END? (3) 8' DIVORCE (3) 0 ANNULMENT 8) ~ DEATJ1 B, HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C, DATE LAST MARRIAGE ENDED? 07 / 02 / 2 0 C. DATE LAST MARRIAGE ENDED? / /
MONTIV DAY YEAR MONTH DAY, '.- YEAR
D. ARE .ANY FORMER SPOUSE(S) ALIVE? dYES 0 NO D, ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF 'tor USN SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 07/02/2004 Poughkeepsie, New YOrK r1 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, aep'ose 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 'mpediment exists
as to my right to enter into the~e staJp. /1 .
21. SIGNATURE OF GROOM. P /pt(!,/~. 2 . SIGNATURE OF BRIDE.
USE C ENT NA E 'US CURRENT NAME
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME 10/04/2006
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license i a~thorizes the marriage in New York State of the ride and groom named above by .any person authorized by New York Domestic
Relations Law ~11toiperform 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.
~ } ~:;~;:I~~ C. ''J8\f~. . a...'. t..e.~.. .' . .\ 10/04/2006 25. A. SOLEMNIZATION PERIOD BEGI::AR MONTH
{ SEAL SIGNATURE~ ~/~~ DATE
~ MAI~M~Cfl~bush''R:cl;'Wappin-ge-r'Falls, NY 12590 12
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. ~
SONS NAMED ABOVE ON THE 0 ELlGIOUS
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
D~TH
YEAR
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ftt7U~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY O~WN OF 0 VILLAGE OF
SPECIFY (YJ::>(.,~ Spf?I/l/C/
j
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~