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COUNTY Dutcb!SS
crrtrrowN Wappinger
~~J~~CRT 1368
~5~~J~R 69
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~rjit SinsnENT SURNAME
FIRST
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~nder Ka~RENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
ll.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER Q5]..ft6..6997
2. RESIDENCE A. ~E~ot:k B. ~es8
c. CHECK ONE 0 CITY ~TOWN 0 VILLAGE
AND Wa.
SPECIFY pplnger
D. STREET ADDRESS 12 stonewall OrJve
B. BIRTH .NAME (MAIDEN NAME), IF DIFFERENT
C. S~S~~m:~~~~~~e~~SE)Kaur Singh
D. SOCIAL SECURITY NUMBER 147021345
12. RESIDENCEA. ~J..~ork B. ~
C. CHECK ONE 0 CITY CJr.,IfOWN 0 VILLAGE
AND \.__ .
SPECIFY vHlppmger
D. STREET ADDRESS 12 stonewall OIW. ZIP 12580
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0 YES c..- NO
M01t / U ~!W
12590
YES [jjf NO
/W3
13.B. DATE OF BIRTH
ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VIlLAGE? 0
/
MOW 0.1
3. A. AGE 30
4. EMPLOYMENT
A. USUAL OCCUPATION Manager
B. TYPE OF INDUSTRY OR BUSINESS SUnoco GIS StItatIon
3B. DATE OF BIRTH
13. A. AGE 26
14. EMPLOYMENT
A.. USUAL OCCUPATION 98188 Associate
B. TYPE OF INDUSTRY OR BUSINESS SI.IROOO QII StltiOR
15. PLACE OF BIRTH _'Q~IlJ"8
16. FATHER
5. PLACE OF BIRTH
6. FATHER
A. NAME Anoop Singh
B. COUNTRy'OF BIR:H Pakistan
7. MOTHER
A. MAIDEN NAME Balblr Keur
B. COUNTRY OF BIRTH Paktlt8R
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
USA)
A. NAME A'ltar Singh
B. COUNTRY OF BIRTH IRds
17. MOTHER
A. MAIDEN NAME Kulwant Kaur
B. COUNTRY OF BIRTH Inde
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL Al!lNULMENT
DEATH
DEATH
o
o
o
(2) 0 DEATH
g. 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
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
(3) 0 ANNULMENT
/ /
YEAR
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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to th
as to my right to enter into the mar~ stat
21. SIGNATURE OF GROOM ~ ~
o 0 1ST 0 0
o 0 2ND 0 0
o 0 ~D 0 0
o 0 4TH 0 0
knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
w
CJ)
Z
W
o
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22. SIGNATURE OF BRIDE ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York Sta
Relations Law ~ 11 to perform marriage ceremonies within
o If checked, this license is t
24. TOWN OR CITY CLERK
DATE
of the bride and groom named above by any person authorized by New York Domestic
ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
be used only for the purpose of a second or subsequent ceremony.
25. A. SOLEMNIZATION PERIOD BEGINS
~
{ SEAL }
'-..t-I
NAME (PRINT)
TIME
MONTH
YEAR MONTH
YEAR
11:51~~ 08
30
08 28 2004
ST
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~OWN OF D' VILLAGE OF
SPECIFY ill) at,/) i J. .3 e tr
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE ~
nn....QR (11JQA\
NAME (PRINT)
SIGNATURE ~