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COUNTY DutchesS
CITYITOWN wapptnger
DISTRICT 1368
NUMBER
REGISTER 5
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
John W. Hilt
I"
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Amisha Bhardwaj
--.J
1. A. FUll NAME
H. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
B. BIRTH NAME, IF DIFFERENT B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Ki r i
C. SURNAME AFTER MARRIAGE C. SURNAME AFTER MARRIAGE Hilt
(OPTIONAL, SEE REVERSE) 079-56-4845 (OPTIONAL, SEE REVERSE) 080-94-5998
D. SOCIAL SECURITY NUMBER D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. New York B Dutchess 12. RESIDENCE A. New York B Dutchess
(STATE) (COUN1Y) (STATE) ~ (COUN1Y)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE C. CHECK ONE Q CITY [J, TOWN 0 VILLAGE
~~~CIFY POU~hkeepsie ~~~CIFY pougnkeepBIe
D STREET ADDRESS 5 B HudSOn HarbOr ZIP 12601 D. STREET ADDRESS 1~ B Huason Harbor ZIP 126'01
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r5 NO E. is RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES [f NO
04 /25 /1962 13. A. AGE 30 13.B. DATE OF BIRTH 09 /07 ~974
MONTH DAY YEAR MONTH DAY YEAR
3. A. AGE 42
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Real Estate
B. TYPE OF INDUSTRY OR BUSINESS Century 21 HuclsOn Valley
5. PLACE OF BIRTH Sacramento. cilltOffila
(CI1Y, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Business
B. TYPE OF INDUSIFIY OR_B'y~II:lE~S tr\ln Int'I U IS A Inc.
15. PLACE OF BIRTH AnmeaaceCl. InCla
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
6. FATHER
A. NAME Pravinchandra Kiri
B. COUNTRY OF BIRTH InClI
17. MOTHER
A. MAIDEN NAME Arunaben JlJlt
B. COUNTRY OF BIRTH India
1 B. NUMBER OF THIS MARRIAGE 2
A. NAME Donald C. Hilt
B. COUNTRY OF BIRTH U S A
7. MOTHER
A. MAIDEN NAME Karen K. Boctcef
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV1RCE CIVIL ANN~LMENT
"
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT ~J..q DEATH
C. DATE LAST MARRIAGE ENDED? 02 / 10 / ~
MONTH oj DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [YVES 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
o 0 1ST 0211012004 Ahmedabad. Indl 0" 0
o 0 ~D 0 0
o 0 ~D 0 0
o 0 4TH 0 0
knowledge and belief that the information I provided is true and that ~ declare that no legall/pediment exists
22. SIGNATURE OF BRIDE ~ I Arnl\,Jl )\I\,tJ.. ~ hCk-t~O<j
USE CURRENT ~
DEATH
o
DEAOH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
YEAR
MONTH DAY
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
a:
Ul
III
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, tha to
as to my right to enter into the marriage at
21. SIGNATURE OF GROOM ~
0113112005
DATE
23. SUBSCRIBED AND SWORN TO BEFOR
SIGNATURE OF TOWN OR CI1Y CLER
This license authorizes the marriage in New York St
Relations Law ~11 tD perfDrm marriage ceremonies withi ew 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) GI '. J. Morse
tJ TIME MONTH
SEAL SIGNATURE ~ -'-'-DATE 01131
'-..,-I MAI~f.ijrcU~ R Falls NY 12590 10: 12AM 02
STREET Cl /TOWN STATE ZIP PM
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 2X?' TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY EAR 0 RELIGIOUS 1 0 CIVIL
DATE AND AT THE TIME AND /.; ,(j, ~
PLACE INDICATED. 7 ~::-. 9 0 OTHER, SPECIFY
W
I- 29. OFFICIANT 1< /3- ) 7 J-J tJ. -; Yl 'JVl, / r-1 /D 17 ~ . I
oCt NAME (PRINT) t1. .~ ;-t I " L-- TITLE' r-v~
~ SIGNATURE ~ l/Vv D U; DATE :J-- / / c.; / oS
i= MAILING ADDRES9-, ? r! / / r::. I I I 1\ I t/ KY1 0
a: / riD 1~ Jr -e.. v / 0 Vi / '"'"?Jvfo.-; I 'f . /. J~J /
W STREET CITYITOWN STATE
(J 30. WITNESS TO CE
by New York Domestic
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YEAR
2B. PLACE WHERE MARRIAGE OCCURRED _ /
-1 Jrd)
A. STATE NEW YORK B. COUNT~ t. ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 4 TOW~ OF 0 VILLAGE OF
SPECiFY l/ 0;/JfJ VI') er
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/9B)
31. WITNESS TO
NAME (PRINT)
SIGNATURE ~