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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~~T 1388
~5~~J~A ~
STATE Of NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT"L1CENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
1. A. FUU NAME
rlai Ki Yani
MIDDLE C RENT SURNAME
FROM THE BRIDE
Haesuk Hona
FIRST MIDDLE CURRENT SURNAME
8. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Hong
c. SURNAME AFTER MARRIAGE Yang
(OPTIONAL. SEE REVERSE) 347 68-0399
D. SOCIAL SECURITY NUMBER -
12. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 ~WN 0 VILLAGE
AND W
SPECIFY aDCinaer
D. STREET ADDRESS 23 FielclstDne Blvd.
11. A. FULL NAME
FIRST
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. ~pl
C. CHECK ONE 0 CITY
AND
SPECIFY
#/A
.
Dutch~c;
(COUNTY)
o TOWN 0 VILLAGE
B.
ZIP Korea
o YES o~O
ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 <0
03 / 27 /1958
MONTH DAY YEAR
D. STREET ADDRESS
33-1 Beonii.
'" .,
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
47
3. A. AGE
49
14. EMPLOYMENT
13.B. DATE OF BIRTH
38. DATE OF BIRTH
13. A. AGE
4. EMPLOYMENT
A. USUAL OCCUPATION Rmall Busi"~c; OWner
B. TYPE OF INDUSTRY OR BUSINESS Agriculture
5. PLACE OF BIRTH Jlnan-kun Korea
(CITY, STATElCOUNTAy IF NOT USA)
6. FATHER
A. NAME Rang Woo Yang
B. COUNTRY OF BIRTH Korea
7. MOTHER
A. USUAL OCCUPATION Beautician
B. TYPE OF INDUSTRY OR BUSINESS Yana Blue Nairs
15. PLACE OF BIRTH Jean-iu. Korea
(CITY, STATEl'COUNTRY IF NOT USA)
16. FATHER
A. NAME Soon Dona
8. COUNTRY OF BIRTH Korea
17. MOTHER
w
en
z
w
(.)
:J
Keun Slm I-Mtang A. MAIDEN NAME . Jae SuI{ Kim
B. COUNTRY OF BIRTH .11Iftn-ju. KftrM B. COUNTRY OF BIRTH Korea
8. NUMBER OF THIS MARRIAGE 2 18. NUMBER OF THIS MARRIAGE 3
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 2 0
8. HOW DID LAST MARRIAGE END? (3) 0 ~ORCE (3) 0 ANNULMENT (2) 0 DEATH 8. HOW DID LAST MARRIAGE END? (3) 0 D,(ORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? M" 18/ 2004 C. DATE LAST MARRIAGE ENDED? Q6/ 28 / 1994
MONTH DAY YEAR MONTH..; DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 'l't!; 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 ~S 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
1 ST 0511 RnM4 Yi~"'Yun. Janjoo-lcun, 0'; 0 1 ST 04102/1987 Du Page Co.. Illinois 0 .; 0
2ND u 0 0 2ND 06/28/1994 Jamaica. New York 0 0 .;
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that tD the be of my knowledge and beltef that the informatIOn I provided is true~nd that I de91are tha~D legal Impediment exists
as tD my right tD enter into the marriag~v1 . \ A. ~
21. SIGNATURE OF GROOM'" ' 22. SIGNATURE OF ~RIDE'" ~/ - \
USE CURRENT NAME ,USE CURREN'1\NAME
23. SUBSCRIBED AND SWORN TO BEFORE ME 05I10l'VV\5
SIGNATURE OF TOWN OR CITY CLERK'" DATE tJlLUU
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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
A. MAIDEN NAME
DEATH
o
YEAR
TIME
MONTH
~
{ SEAL }
'-y-I
NAME (PRINT)
0511
lis NY 12590
STATE ZIP
27. TYPE OF CEREMONY
DATE
11:3!I
PM
05
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ])J1'CJ+~'l
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY 0 0 RELIGIOUS
DATE AND AT THE TIME AND ./ db.. r f
PLACE INDICATED J:I!!\ ..::::> 90 OTHER, SPECIFY C.
29 OFFICIANT ~~cE-fv( ~>Clf1fJCE.~E 1:",_<:.07 -iF.., .) ..,.. ....:ttqfff
~,",,''''n A _ _ ~ . ,'\ , me< .,,'''-~ ~wUJs' I c~
SIGNATURE ...~7;J'Ah w.L---OATE IlJAlf fcr, <J...4>'6f
MAILING P9DRE~~ 10 tl \
I ( /\;;~ VOl "'- r i... /;Vft(.Pcr0G-f.::Qg" FRJ...hS NY,. l2f;p()
STREET CITYrrOWN STATE I ZIP
30. WITNESS TO CERE~MONY . / I (""'> __ 31 WITNESS TO CEREi,ONY r.- \' 'F.' ,::;
~"' I''''" S/fI2f/ iI f7. J C H (N D 1fL ~"""''" fJ N Ci;.AF!,/} "'.:- tef/A.C-S'.Jf
SIGNATURE'" ~. q. ~~~_ SIGNATURE'" 7LA1fW~/Je. if, J;(J.-1.-/
DOH-98 (11/9B)
1")t, CIVIL
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF !llI( TOWN OF 0 VILLAGE OF
SPECIFY {Al ,q.PPf!\)GE~