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, COUNTY Df ttcl'l~s
CITYfTOWN Wappinger
~~J~~~ 1368 .
~5~I~J~R 112
::s I A II:. UI- NI:.W YUHK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
1-i~~~llng Chef ~'JSENT SURNAME
.;:)1"'11; r....c:. '.UMDc:.n
(THIS SPACE FOR STA TE USE ONL Y)
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Van Dai
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
a-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~rJN~~~~~~e~~sf?heung
D. SOCIAL SECURITY NUMBER 095-8?~Rl1F\tl
12. RESIDENCE A. N ~TATE) B. D\~'"
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND Wa .
SPECIFY pp1nger
D. STREET ADDRESS 35 Re.ggI~ Driv~ ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES!!!l NO
13. A. AGE 24 13.B. DATE OF BIRTH ~H A~AY ,(97~
14. EMPLOYMENT
A. USUAL OCCUPATION Ar.r.nuntant
B. TYPE OF INDUSTRY OR BUSINESS st Cabrinl Home
15. PLACE OF BIRTH China
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Wen Vun Oai
B. COUNTRY OF BIRTHChlna
17. MOTHER
A. MAIDEN NAME Sheng FeI Zhang
B. COUNTRY OF BIRTHChlna
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER ~~RO..~~
2. RESIDENCE A. N ~ATE) B. ~~...
C. CHECK ONE 0 CITY III TOWN 0 VILLAGE
AND W .
SPECIFY 8pp1nger
D. STRm ADDRESS 35 Re;gie Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES tl NO
3. A. AGE 31 3B. DATE OF BIRTH M~"l / ~ /12.73
4. EMPLOYMENT
A. USUAL OCCUPATION A~untant
B. TYPE OF INDUSTRY OR BUSINESS Fidelity Investmems
5. PLACE OF BIRTH China
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME Tim Chun Cheung
B. COUNTRY OF BIRTH China
7. MOTHER
A. MAIDEN NAME Kwal ChI'" Lam
B. COUNTRY OF BIRTH China
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNUUMENT
o 0
DEATH
o
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) D DEATH
C. DATE LAST MARRIAGE ENDED? / /
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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
1D. 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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III
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly SWDrn, depose and say, that to the best of my knowle ge and belief that t e information I provided is true and that I declare that nD legal imp Imen! exists
as to my right to enter into the marri estate. ~ a '"
21. SIGNATURE OF GROOM ~;r 22. SIGNATURE OF BRIDE ~ ~ 7 ~~
SE CURRENT NAME
23. SUBSCRIBED AND SWORN TO BEFOR E 09,~aI"VV\A
SIGNATURE OF TOWN OR CITY CLERK~ DATE 'UWLUU"t
This license authorizes the marriage in New York State f 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 pu ose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLE.RK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) GI
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
"-v-I M~~D elXfsh Rd
STREET
I CERTIFY THAT I SOLEMN
THE MARRIAGE OF THE
SONS NAMED ABOVE ON
DATE AND AT THE TIME
PLACE INDICATED.
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YEAR
ZIP
08:35 AM 09
PM
07 2004
09
2004 11
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNrv!) U-(c.I1€J:
C.
29. OFFICIANT
NAME (PRINT)
o CITY OF TOWN OF 0 VILLAGE OF'
SPECIFY DK'f" h.s~/L"t..-
SIGNATUR~~
DOH-98 (11/98)
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