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CITY/TOWN Wappinger
~lTr~:~~T 1368
~5~~J~R 186
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
V\(MDX'ong HuaQQRENT SURNAME
~
I
QJb,
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
f17H/(R,ItGIJ Nt1J6R. .
~ ;()tI~ 1JPNt ' ~ IIfJf~ef)
~91-q&7r; J-~~.o'3. f{EtJ,'5fYe
L 0 SUPPLEMENTAL FILE .~ i~ ~
I
1 A. FULL NAME
11. A. FULL NAME
FROM THE BRIDE
F~DJ;;fpi ChellrlQURRENT SURNAME
FIRST
FIRST
"-
N
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C S~~~~~N~r;:rE~~t~~e~~sgheung - Huang
D SOCIAL SECURITY NUMBER CJ59..8O...7818
12. RESIDENCE A~A);prk B. ~lmo~9
C. CHECK ONE 0 CITY iii TOWN 0 VILLAGE
AND \AI .
SPECIFY napplnflet-
D. STREET ADDRESS.~ R~ie f'lriVR ZIP 1 ?5..QO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
13. A. AGE25 13.8 DATE OF BIRTH MU'H /1~t /<f~1A1
14. EMPLOYMENT
A. USUAL OCCUPATION Teller
B. TYPE OF INDUSTRY OR BUSINESS Trustco Bank
15. PLACE OF BIRTH~/c~~ NOT USA)
16. FATHER
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER 09S 70..3840
2. RESIDENCE A N~T'tOrk B. ~)
C. CHECK ONE tIJ CITY 0 TOWN 0 VILLAGE
AND
SPECIFY New York
D STREET ADDRESS 1848 80th Street ZIP 11214
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES III"J NO
M~ /QA /1914
3. A. AGE 28
4. EMPLOYMENT
38 DATE OF BIRTH
A. USUAL OCCUPATION Computer Technician
8 TYPE OF INDUSTRY OR BUSINESS Compuforce
5. PLACE OF BIRTH~ ~,
. C NOT USA)
6. FATHER
A. NAME Yu Min Huang
B. COUNTRY OF BIRTH China
7. MOTHER
A. MAIDEN NAME Xi" Van Mai
8 COUNTRY OF BIRTH China
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
A. NAME Tim Chun Cheung
8 COUNTRY OF BIRTtChtna
17. MOTHER
A. MAIDEN NAME Kwai Chun Lam
8 COUNTRY OF BIRTt-China
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
o
(3) [J DIVORCE
o
(2) 0 DEATH
o
o
(3) 0 DIVORCE
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 ANNULMENT
/ /
B. HOW DID LAST MARRIAGE END?
(3) 0 ANNULMENT
/ /
C DATE LAST MARRIAGE ENDED?
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
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
YEAR
15T 0 0 15T 0 0
2ND 0 0 2ND 0 LJ
3RD 0 0 3RD [J 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare th t no legal impediment exists
as to my right to enter into the marriage state. .'\
21. SIGNATURE OF GROOM ~
22. SIGNATURE OF BRIDE ~
W
en
z
W
o
..J
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~ DATE 12/0612002
This license authorizes the marriage in New York person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wit New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
[] 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
,-'-.,
{ ~NAME (PRINT)
SEAL.. . ~GtitriJ E ~ ..-
\.., MAILING ~DORESS
","-v-/
MONTH
YEAR
MONTH
YEAR
AM
PM
12
07
2002 02
04 2003
S
,.'t;ERTJFY THAT I SOLEMNIZED
~."tHE MARRIAGE OF THE PER.
SO. NS IIfAM~fi..ABOVE. ON THE
DATE AND.: I\f' THE TIME AND
.PLAC&.INoICA.~EE::.~ ,~. ,"
Wt-.'. .J .;.....,., ,
/29. OFF~IIINt.,;./ ,. ,'.
<C 'NAME(Pf)oIN'rJ '. "!:'..4.
2 ,r, '.. ""','..4;,"
LL SIGNATURE.. ;.tt,
i= MAILI~tpDRESS."
a: ,r, {l
W STREET
o 30. WITNESS TO CEREMONY
26 SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
AM
PM
28. PLACE WHERE MARRIAGE OCCURRED
o 0 RELIGIOUS
9 0 OTHER. SPECIFY
10 CIVIL
A. STATE NEW YORK 8 COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
TITLE
'"
"
DATE
SPECIFY
CITY/TOWN
STATE
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH.98 (11/98)
NAME ~PRINT)
SIGNATURE ~