011
STATE. OF NEW YORK I STATE FilE NUMBER I
COUNTY Dutchess (THIS SPACE FOR STA TE USE ONL YI
. CITYITOWN Wappinger DEPARTMENT OF HEALTH
~~J~~CRT 1368 AFFIDAVIT, LICENSE and
~5~I~J~R 11 CERTIFICATE OF
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
1. A. FULL NAME Ikram Mrani 11. A. FULL NAME Mari1za L Arriaaa
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
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B. BIRTH NAME, IF DI FFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 132 74 0142
D. SDCIAL SECURITY NUMBER -.
2 RESIDENCE A. New York B. Dutchess
(ST A Tit (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VilLAGE
~~~CIFY Poughkeepsie
D STREET ADDRESS 99 Uvingston street Apt. lO&> 12601
E. IS RESIDENCE WITHI: L~;S OF CITY OR INCORPORATED VILLAGE? c/ YES 0 NO
01 / 30 / 1984
MONTH DAY YEAR
3. A. AGE 21
3B. DATE OF BIRTH
R BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mrani
(OPTIONAL - SEE REVERSE) 1 01 ~o5902
D. SOCIAL SECURITY NUMBER -go-
12. RESIDENCEA. New York B. Dutchess
(STATE1 (COUNTY)
C. CHECK ONE [Y" CITY 0 TOWN 0 VilLAGE
AND P ahar...........i
SPECIFY ou ~e
D STREET ADDRESS 991jyjngston street Apt. l03p 12601
E. IS RESIDENCE WITHI~ ~';TS OF CITY OR INCORPORATED VILLAGE? ~YES 0 NO
nR /1R A~
MONTH DAY YEAR
13. A. AGE ?O
14. EMPLOYMENT
A. USUAL OCCUPATION customer Service
B. TYPE OF INDUSTRY OR BUSINESS B J's VJholesale Club
15. PLACE OF BIRTH Bronx New York
(CITY. STA1E1COUNTRY IF NOT USA)
16. FATHER
A. NAME Salvador Ani.! Jr
8. COUNTRY OF BIRTH USA
13.B. DATE OF BIRTH
17. MOTHER
A. MAIDEN NAME Mildred Aree
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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(2) 0 DEATH
4. EMPLOYMENT
A. USUAL OCCUPATION student
8. TYPE OF INDUSTRY OR BUSINESS Dutchess
5. PLACE OF BIRTH Queens. New V ork
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME Mohamed A Mrani
B. COUNTRY OF BIRTH Morocco. North Africa
7. MOTHER
A. MAIDEN NAME AlMa DJarlludlb
B. COUNTRY OF BIRTH Algeria, North Africa
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
(2) 0 DEATH
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
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MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State by New York Domestic
Relations Law ~11 to perform marriage ceremonies within w 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) Gloria
TIME MONTH MONTH YEAR
SEAL SIGNATURE ~
MAILING ADDRESS AM
'-v-I . 01 :50PM 02 04 16 2005
28. PLACE WHERE MARRIAGE OCCURRED
CIVIL A. STATE NEW YORK B. COUNT:l)U.1'cJI1:t.l
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF ~LLAGE OF
SPECIFY WHl',A::6t1Z& ~
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21. SIGNATURE OF GROOM ~
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SIGNATURE ~