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COUNTY Dutchess
CITYfTOWN Wappinger
1368 .
155
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
MIDr~t Yi Che~~RENT SURNAME
I
STATE F1t.E NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
DISTRICT
NUMBER
REGISTER
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Qinwen ZhanQ
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Zh a n q
(OPTIONAL' SEE REVERSE) 127-84-4360
D, SOCIAL SECURITY NUMBER
12. RESIDENCE A. Vermont 8. Rutland
(STATE) (COUNTY)
C. CHECK ONE 0 CITY O.....TOWN 0 VILLAGE
~~~CIFY Rutland
D STREET ADDRESS 239 E. Ridge Terrace ZIP 05701
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d'" NO
01 / 18 /1978
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 128-78-1566
D. SOCIAL SECURITY NUM8ER
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 01 TOWN 0 VILLAGE
~~~CIFY Pouqhkeepsie
D. STREET ADDRESS 28 Colette Drive
12601
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ct NO
06 / 25 / 197
MONTH DAY YEAR
13. A. AGE 28
3B. DATE OF BIRTH
3. A. AGE 29
3B. DATE OF BIRTH
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION
Unemployed
4. EMPLOYMENT
A. USUAL OCCUPATION
Chef
B. TYPE OF INDUSTRY OR BUSINESS Chinatown Restaurant
5. PLACE OF BIRTH Fujian, China
(CITY. STATE I COUNTRY IF NOT USA)
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Fujian, China
(CITY. STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Zi-Peng Zhang
'B. COUNTRY OF BIRTH China
17. MOTHER
6. FATHER
A. NAME Sum Yuk Chenq
B. COUNTRY OF BIRTH China
7. MOTHER
A. MAIDEN NAME Lanhua Lu
B. COUNTRY OF BIRTH China
1
Yuk Kam Wong
B. COUNTRY OF BIRTH China
B. NUMBER OF THIS MARRIAGE 1
A. MAIDEN NAME
1 B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
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
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
C. DATE LAST MARRIAGE ENDED?
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) (Cl.TY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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
o 0
o 0
o 0
o 0
no legal impediment exists
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o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
wledge and belief that the information I provided is true and that I declare t
09/22/2006
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE
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
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 purpose of a second or subsequent ceremony.
24. TOWN OR CITY J:iRK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
by New York Domestic
~
{ SEAL }
'-v-I
YEAR
DATE 09/22/200
appinger Falls, NY 12590
CITYrrOWN STATE ZIP
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
MO. DAY YEAR 0 0 RELIGIOUS
O(g 90 OTHER, SPECIFY
SIGNATURE ~
MAILI~jISlfasd1 e
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
26. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~ (lYe ko ~(
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF .g.-tOWN OF 0 VILLAGE OF
SPECIFYU)11 fP) 1je r
1~IVIL
29. OFFICIANT
NAME (PRINT)
S E
30. WITNESS TO CEREMONY
NAME (PRINnV{\f\\ II \t Uf\.~
SIGNATURE ~ 'D C}..(\ ~ ~J \ t U r---::::::>
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~