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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
FazaI Mohammed
COUNTY ~
CI1VITOWN ::p;Anr:JfJf
""iTRICT 1
./MBER
REGISTER W
NUMBER
1. A. FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 118-70.7073
D. SDCIAL SECURITY NUMBER
2. RESIDENCE A. New Yark
(STATE) ->>'
C. ~~5CK ONE pl"i. 9...~~ JL10WN
SPECIFY VU}lllImepllle
D. STREET ADDRESS 610 Maloney ROIO APE. ~
B. Dutchess
(coUNTY)
D VILLAGE
12t5W
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES r1 NO
3. A. AGE 33 3B. DATE OF BIRTH 02 / 26 / 1971
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION 8ectrorics Technician
5. :~::~~:,::US~lnhliln: ==ttn COrp.
(CITY, STATEICOUNTRY IF NOT USA)
6. FATHER
A. NAME Irnzsck Mohammed
B. COUNTRY OF BIRTH TnnlCIICl
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Frances M. Centamore
MIDDLE CURRENT SURNAME
-1
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mohammed
(OPTIONAL - SEE REVERSE) I'U:!ft ~ DnE5
. D. SOCIAL SECURITY NUMBER ~J
12. RESIDENCE A. New York B. Dutchess
(STATE).......tL . (COUNTY)
C. CHECK ONE D CITY LlTOWN D VILLAGE
~~~CIFY pough~e
D. STREET A~810ney Roed P#. ~P 12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? DYES rf NO
02 /03 /1973
MONTH DAY YEAR
13. A. AGE 31
13.B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Waitress
B. TYPE OF INDUSTRY OR BUSINESS Union House
15. PLACE OF BIRTH Newburah, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME Santa Centamore
B. COUNTRY OF BIRTH USA
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23. ~~;.fT~=~Do~Ni'o~O~~ ririv 6J:~~E OATE 0811612004
This license authorizes the marriage in New York Sta authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CI~C;:LE8K 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) ~0118 J. Marse
{ tl TIME MONTH
SEAL SIGNATURE ~ - . TE 0811612004
'-..,-l MA~~ R Falls, NY 12590 02:40~~ 08
STR ET C rr WN STA ZIP
~~~R~t~RT~~~ IO~O~~~N~t~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 D RELIGIOUS A?IVIL
DATE AND AT THE TIME AND 0 t/
PLACE INDICATED. 7 9 D OTHER, SPECIFY
m~4(
DATE rO 1
7. MOTHER
A. MAIDEN NAME Nazmoon All Slh81
B. COUNTRY OF BIRTH Trlnldld
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVO'(JE CIVIL ANN~LMENT
DEAf)
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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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30 WITNESS TO cyrEMONY
NAME (PRINT) l! ~.t~ : ~ ~/l ~
SIGNATURE~ ~~~
DOH-98 (11/98)
~c.
c .
17. MOTHER
A. MAIDEN NAME Jenny De VIto
B. COUNTRY OF BIRTH USA
2
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) ~IVORCE (3) D ANNULMENT Ai DEATH
C. DATE LAST MARRIAGE ENDED? 02 / 03 / 1
MONTfiJ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ITYES D 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
02103I1998 Goshen. New York r:I'
DEATH
o
D 1ST
D 2ND
D 3RD
D 4TH
ief that the Information I provided is true
D
D D
D D
D D
pediment exists
22. SIGNATURE OF BRIDE
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~Gtf
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF D TOWN OF ~VILLAGE OF
SPECIFY 6rn1/ll",~/- fJ,.rk-
NAME (PRINT)