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1. A FULL NAME
::i I A II: Uf- NI:.W YURK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Danie.l
:;, I A II: r-ILI: NUMI:S~H
(THIS SPACE FOR STATE USE ONLY)
COUNTY Dutchess
CITYITOWN Wappinger
~5'~~kc~ 1368
~5~I~J~R 44
--1
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
11. A. FULL NAME Halima
Fehdi
CURRENT SURNAME
Galan
CURRENT SURNAME
FIRST
MIDDLE
FIRST
MIDDLE
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A New York B. Dutchess
(5T A TE) (COUNTY)
o CITY 0 TOWN ~ VILLAGE
Wappingers Falls
D. STREET ADDRESS 6221 Princess Circle
12590
Fehdi
053-94-5455
B BIRTH NAME. IF DIFFERENT
C. SURNAME AffiR MARRIAGE
(OPTIONAL - SEE REVERSE) 135 64 9703
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
o STREET ADDRESS 2600 South Rd. 44-183 ZIP 12601
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Kl NO
3. A AGE 41 3B.DATEOFBIRTH 08 /23 /1963
MONTH DAY YEAR
C. CHECK ONE
AND
SPECIFY
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Kl YES 0 NO
13. A. AGE 30 13.B. DATE OF BIRTH 04 / 01 /1975
MONTH DAY YEAR
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION Operator
B. TYPE OF INDUSTRY OR BUSINESS IBM Corp.
15. PLACE OF BIRTH Khenifra, Moracco
(CITY, STATElCOUNTRY IF NOT USA)
A. USUAL OCCUPATION Elec tronics Engineer
B. TYPE OF INDUSTRY OR BUSINESS IBM Corp.
5. PLACEOFBIRTH BarranQuilla, Colombia
(CITY, STATElCOUNTRY IF NOT USA)
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
Mohammed Fehdi
Morocco
6. FATHER
A. NAME Miguel Galan
B. COUNTRY OF BIRTH Colombia
7. MOTHER
A. MAIDEN NAME
B. NUMBER OF THIS MARRIAGE
Moloda Afif
Morocco
1 B. NUMBER OF THIS MARRIAGE 1 s t
Maria Sepulveda
Colombia
2nd
A. MAIDEN NAME
B. COUNTRY OF BIRTH
B. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE END? (3) I>> DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08 / 23 / 2000 c. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? iXYES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
08/23/2000 Burlington, Venoont 00 1ST 0 0
o ~ 0 0
o ~ 0 0
o ~ 0 0
belief that the information I provided is true and that I declare that no legal impediment exists
\ \ ~ ~'^^O- \="" e. ~ c.L
r USE CURRENT NAME
YEAR
22. SIGNA1\JRE OF BRIDE ~
J#61101-L
21. SIGNATURE OF GROOM
06-02-2005
DATE
w
en
z
w
u
:J
23. SUBSCRIBED AND SWORN TO 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
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 CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) Sandra
MONTH
YEAR
by New York Domestic
~
{ SEAL }
'-.,-;
YEAR
TIME
MONTH
SIGNATURE ~
MAILING ADDRESS
20 Middlebush
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
3: 15 PM
06
03
2005
08
01
2005
ers Falls
STATE
27. TYPE OF CEREMONY
00 RELIGIOUS ~IL
9 0 OTHER, SPECIFY
ZIP
2B. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY O~OWN OF 0 VILLAGE OF
SPECIFY Watpi ~ e r
29. OFFICIANT
NAME (PRINT)
TITLE ~ .,.....,...~" r {')f;:{;.o c..€ ,
DATE (^ h/') II) ~
t I
o
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) /'10M- M f'i\ E1:>
SIGNATURE ~ /I( I? k' (7tLe,f(2l
M A ,o.N A-l'J ~
It( O'okOuf2