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1. A. FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I\qW R MehtlDDLE
I
STAle fILe NUMBl:R
(THIS SPACE FOR STATE USE ONLY)
COUNTY n.1Mh~
ClTYfTOWN \Ngppl~
~~~1~
~5~1~~R 57
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~
11. A. FULL NAME Kn.fIiJ '1!INJIr
MIDDLE
CURRENT SURNAME
CURRENT SURNAME
..
j;j
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SW~~~~~~~Mebta
D. SOCIAL SECURITY NUMBER
12. RESIDENCEANelMA~
C. CHECK ONE 0 CITY ~ TOWN 0
~ClFYpnlls#'~A
D. STREET ADDR~AA2A Aldtftn PArk RftAd Zlf'1~~
E. IS RESIDENCE Wl1lltN UMIlS OF CITY OR INCORPORA'lED VWGE? 0 YES~ NO
38. DATE OF BIRTH ~ i4DAy ~
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl' SEE REVERSE)
O. SOCIAL SECURITY NUMBER 11 ~ 70- 7?11
2. RESIDENCE A. N",~aJk B. ~
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFY Potlgb~e
D. STREET ADDRESS 24 AI dtnn PArIr RNId ZIP 1~~
E. IS RESIDENCE WITHIN UMIlS OF CITY OR INCORPORATED VILLAGE? 0 YES~ NO
~ /QB /Wf'8
B.~
VILLAGE
13. A. AGE23
14. EMPLOYMENT
A. USUAL OCCUPAlloNUnemplayed
B. lYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIR1lI~ Incle
(, I COUNTRY IF NOT USA)
16. FATHER
~
In
3. A. AGE28
4. EMPLOYMENT
A. USUAL OCCUPAllON SaIlware Developer
B. TYPE OF INDUSmy OR BUSINESS Lebmen Br~
5. PLACE OF BIRTH Aal'ftlta IntlA
~IFNOTUSA)
6. FATHER
A. NAMEKililkum8r CbBndfFhAnlaitr TewBr
B. COUNmY OF BlRTI4nde
17. MOTHER
A. MAIDEN NAME RenF'A Perv\'e
B. COUNmY OF BIRTI4nd1e
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
3B. DATE OF BIRTH
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A. NAME R8mesh Meta
B. COUNmY OF BIRTH Inda
7. MOTHER
A. MAIDEN NAME Rekb8 Desel
B. COUNmY OF BIRTH Inde
8. NUMBER OF THIS MARRIAGE 1
9. ~R~~~~~RMO'}R~~T8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
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o
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEAlH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) AUVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (ClTYICOUNTY. STATEICOUNTRY. IF NOT USA) SELF SPOUSE
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEAlH
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 INFORMAllON
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
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1ST 0 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, dep'DSe and say, that to the best of my knowledge and belief that the infonnation I provided is true and that I declare that no legal impediment exists
as to my right to enter into the mamage state.
21. SIGNATURE OF GROOM ~ :lURE OF BRIDE ~ -1-< 'k' ~ (J cJ Cl a-""
SE CU USE CURRENT NAME
23. ~~~~~~o~~~J;~ C~:~ BEFORE ME DATE ~
This license authorizes the marriage In New York State of authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York tate. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used on se of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SQLEMNlZAllON PERIOD BEGINS
,-^-.
{ SEAL }
'-v-'
llME
MONTH
YEAR
MONTH
YEAR
p
AM
12:15 PM 05
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCAllON OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF .3"fOWN OF 0 VILLAGE OF
SPECI~I~~/
07
22 2006
24
2006
~IVlL
('
S EET ClOWN
30. WITNESS TO CEREMONY 111
"'...--f~ ~.
SIGNATURE~ "AD-\. ~
DOH-98 (0712005)
/" . NAME (PRINT)
SIGNATURE~