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COUNTY [)ut~
CITYITOWN WAppinger
R:JJ~kW 1368
~G~~J~R 11
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
~reaDrv.1 ThP.W
MIDDLE'"' - 1 CURRENT SURNAME
I
STATE RLE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
~
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~~ ....Jp-n . JP-~ENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAl - SEE REVERSE)
D. SOCIAL SECURllY NUMBER
B. , BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE . Jeng
(OPTIONAl - SEE REVERSE)
D. SOCIAL SECURllY NUMBER 57R-7~,}
12. RESIDENCE A. ~Ernrk' B. ~~
C. CHECK ONE 0 CITY 0 .;oWN 0 VILLAGE
AND ,...r-.
SPECIFY v-,ppflgP-r
D. STREET ADDRESS 5TAngfAWtJOd 0rIv1t ZIP
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
13. A. AGE 47 13.B. DATE OF BIRTH MQ3iQ / ~
14. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
15. PLACE OF BIRTH, (II'-I~JtT USA)
16. FATHER
A. NAME Shaur- Show, Jeng
B. COUNTRY OF BIRTH China
17. MOTHER
A. MAIDEN NAME Room may'NaAg
B. COUNTRY OF BIRTH China
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
11().4t\. 7403
2. RESIDENCE A. New Vode B n.dcllP-KR "
'~TATE) .~
C. CHECK ONE 0 CITY o;rOWN 0 VILLAGE
AND
SPECIFY ~ppi"gP-F'
D. STREET ADDRESS 5 TAngJ~ Orlvlt
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE?
1~5M
YES Dl"No
/1~
ZIP 1~5CIO
DYES []tINO
3. A. AGE 41
4. EMPLOYMENT
A. USUAL OCCUPATION
3B. DATE OF BIRTH
B. TYPE OF INDUSTRY OR BUSINESS
5. PLACE OF BIRTH
6. FATHER
A. NAME Gauet Lewis Thew
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Judth GertRlde Roth
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
o
o
(2) 0 DEATH
1 0 0
B. HOW DID LAST MARRIAGE END? (3) 0 IItvORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 04/"4 / ..~
MONTH Di(f' YiP
D. ARE ANY FORMER SPOUSE(S} ALIVE? 0 ~S 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
8. 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
YEAR
o 0 1ST 04124/1989 Toledo, Ohio 0'; 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
ledge and belief that t e information provided is true and that I declare that no legal impediment exists
2 SIGNATURE OF BRIDE ~ a' -- tl-- h
~ U~NTNAE
23. SUBSCRIBED AND SWORN TO BEFORE
SIGNATURE OF TOWN OR CIlYCLERK DATE 03I02Q004
This license authorizes the marriage the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within Ne ork 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
1ST
2ND
3RD
4TH
I, being duly SWDrn, depose and say, that to t
as tD my right to enter into the marriage ate.
21. SIGNATURE OF GROOM ~
~
{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
YEAR
YEAR
MONTH
TIME
MONTH
11:~~
01 2004
03
05
03
ZIP
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
l~VIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEWYORK 8. COUN.;Lu~S
C. LOCATION OF CEREMONY
rCHECK ONE AND SPECIFY}
o CITY OF TOWN OF 0 VILLAGE OF
NAME (PRINT)
SIGNATURE ~