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COUNTY Dutchess
CITY~OWN Wappinger
~~J~~c~ 1388
~5~I~l~R 81
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I=ArIi ~tJ~lil
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L D SUPPLEMENTAL FILE
,. A. FULL NAME
FROM THE BRIDE
11. A. FULL NAME FIRST Al\tp SuleimmENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Nesheiwat
c. S~S~~rJN~~~~~t~~e~~s&<halil
O. SOCIAL SECURITY NUMBER 12Q.. 7 4-0536
12. RESIDENCEA.~ B. Of~
C. CHECK ONE iI CITY 0 TOWN 0 VILLAGE
~~CIFY ni1Anrtn
D. STREET AODRESS.41~ Tall TrAA DrivlIJ ZIP 32810-
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
'p.
~aH ~AY 4'9~
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 1 ~?-76-~989
2. RESIDENCE A. N ;tATE) B. ~~
C. CHECK ONE 0 CITY ii!I TOWN 0 VILLAGE
~~CIFY Poughk~e
D. STREET ADDRESS 44 Old Farms Road ZIP' 12803
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
M~ / Q?y /1212
13.B. DATE OF BIRTH
13. A. AGE 19
3. A. AGE 32
4. EMPLOYMENT
A. USUAL OCCUPATION Self. EmplQ}'ed
B. TYPE OF INDUSTRY OR BUSINESS Own Busln~c:.
5. PLACE OF BIRTH Irbed Jordan
(CITY, S"ATElCOUNTRY IF NOT USA)
6. FATHER
A. NAME Issa Khalil
B. COUNTR~ OF BI~TH Jordan
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION I Jnp.mplnyNt
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH ~~ JiM't()ri(
( , ., I T SA
16. FATHER
A. NAME RiAll;, A NP.!:thP.iwAt
B. COUNTRY OF BIRTHJDrdan
17. MOTHER
A. MAIDEN NAME NIdI E. Qaqlsh
B. COUNTRY OF BIRTH. Jordan
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o ' 0
DEATH
(1
7. MOTHER
A. MAIDEN NAME Hl.da Fakho1lrl
B. COUNTRY OF BIRTH .Jordan
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY
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
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
YEAR
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
1ST 0
2ND 0
3RD 0
4TH 0
I, being duly SWDrn, depose and say, that to the best Df my knDwledge an
as to my right to enter into the marria state. ..
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21. ~IGNATURE OF GROOM~
23. SUBSCRIBED AND SWORN TO B ORE ME 0" """""A
SIGNATURE OF TOWN OR CITY CLERK ~ DATE '11.-':UI'LUU"t
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 onl for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Glori
TIME MONTH YEAR MONTH DAY
SEAL SIGNATURE ~
M~lJrc'D~h R AM 21 2004 09 18 2004
'-,-I STREET STATE ZIP 02:33 PM 07
~~~R~:Ri':~ 'o~O!r:N~E~ 26. SOLEMNIZATION 27. TYPE OF CEREMONY 28. PLACE WHERE MARRIAGE OCCURRED
SONS NAMED ABOVE ON THE TIME M 6)(RELlGIOUS 10 CIVIL Qlf/'lt~c,,5
DATE AND AT THE TIME AND NrIt A. STATE NEW YORK B. COUNTY' 1 1 ;; ~
PLACE INDICATED. PM 9 0 OTHER, SPECIFY
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25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
29. OFFICIANT
NAME (PRINT)
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
)'(cITY OF 0 TOWN OF 0 VILLA~E OF
SPECIFY f" "'8~ J It>,
NAME (PRINT)
SIGNATURE~