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COUNTY Dutchess
CITYfTOWN Wappinqer
~~~~:f; 1368 .
~5~I~J~R 152
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Mabel Jeanette Adams
MIDDLE CURRENT SURNAME
-1
1. A. FULL NAME
Gamal MahmOIJd Shamroukh
MIDDLE CURRENT SURNAME
FIRST
11. A. FULL NAME
-
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 225 59 0540
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE A. New York B. Brooklyn
(STATE] (COUNTY)
C. CHECK ONE [l1f CITY 0 TOWN 0 VILLAGE
~~~CIFY Brooklyn
D. STREET ADDRESS 320 82nd Street, Apt. 1 ZIP 11209
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? d"" YES 0 NO
3. A. AGE 42 3B. DATE OF BIRTH 07 / 12 / 1964
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Adams - Shamroukh
(OPTIONAL. SEE REVERSE) 093-36-8072
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cY TOWN 0 VILLAGE
~~~CIFY Wappinqer
D. STREET ADDRESS 14 His Way ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES c'1 NO
13.A. AGE 59 3B.DATEOFBIRTH 03 /21 /1947
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Human Resources Assistant
B. TYPE OF INDUSTRY OR BUSINESS West Point Military
15. PLACE OF BIRTH New York, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME William Warren Adams
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Natalie Gaitan
B. COUNTRY OF BIRTH USA
5
18. NUMBER OF THIS MARRIAGE
4. EMPLOYMENT
A. USUAL OCCUPATION Store Manager
B. TYPE OF INDUSTRY OR BUSINESS Porta Bella
5. PLACEOFBIRTH Alexandria. Eqypt
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Mahoud Shamroukh Abdelmoein
B. COUNTRY OF BIRTH E~NPt
7. MOTHER
A. MAIDEN NAME Fatima Zedan Elsayed Farg
B. COUNTRY OF BIRTH E~NPt
8. NUMBER OF THIS MARRIAGE 2
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9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH DIVORCE CIVIL ANNULMENT
1 0 0 3 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) O~IVORCE (3) 0 ANNULMENT (219 DEATH
C. DATE LAST MARRIAGE ENDED? 04/ 27 / 1998' c. DATE LAST MARRIAGE ENDED? 06 / 13 / 198
MONTH " DAY YEAR MONTH !<I DAY' '. - YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONT'A DAY1 YEAfJl. (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 04/27/1998 Norfolk, Virginia 0 0..... 1ST 09h2/ 970 Bronx, New York 0 rf
2ND 0 0 2ND Uf/1U/19Bo urange <';0., New YOrK 0 r!f
3RD 0 0 3RD 06/13/1997 Wyandotte <';0., Kansas 0 r!f
~ 0 0 ~ 0 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is I impediment exists
as to my right to enter into the marnage st .
DEATH
1
21. SIGNATURE OF GROO
USE C RE
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
W Relations Law ~11 to periorm marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
tn 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
Z ~ 24. TOWN OR CITYJCL RK C M 25. A. SOLEMNIZATION PERIOD BEGINS
W } NAME (PRINT) 0 . asterson
3 {SEAL SIGNATURE" DATE 09/13/200 TIME MONTH DAY YEAR MONTH DAY YEAR
L- -J MAI~O'lOO'Cfat appinger Falls, NY 12590 ,f.M 09 14 2006 11 12 2006
-v- 04:04:>M
STREET CITYITOWN STATE ZIP
~~~R~~Ri~~J IO~O~~~N~~~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY _./'
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 ~VIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER. SPECIFY
DATE
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
28. PLACE WHERE MARRIAGE OCC~
A. STATE NEW YORK B. cou w,TC:Jfs$.
C. LOCATION OF CEREMONY
(CHECK ONE~NDYECIFY)
o CITY OFP-rOWN OF 0 VILLAGE OF
t r.n8 ,J. fC,.,'I,.,L..
SIGNATURE" *