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COUNTY nutchess
CITYfTOWN Wappinger
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Rashmi Sharma
..J
1. A. FULL NAME
Pr;::)rl~Ap ~h,mdr;::)
MIDDLE. CURRENT SURNAME
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT M ishra
c. SURNAME AFTER MARRIAGE Chandra
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York
~ATE)
C. CHECK ONE 0 CITY r!! TOWN
~~~CIFY Fishkill
STREET ADDRESs53.Hiahland Court ZIP 12524
IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
l' /'1 ..1951
MONTH DAY YEAR
11. A. FULL NAME
CURRENT SURNAME
..
;::;
fiRST
B. BIRTH NAME, IF DIfFERENT
C. SURNAME AFTER MARRIAGE
D. sci~I7t:I~:-m,;E:u:~~RSE)1mV'iR-~711
2. RESIDENCE A. N~WA~nrk B. ~ss
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~CIFY F'i~hkill
D. STREET ADDRESS 53 Highland Court ZIP 12524
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
3. A. AGE 53 3B. DATE OF BIRTH ~ / ~~ / ~
4. EMPLOYMENT
A. USUAL OCCUPATION Phy~~i;::)n
B. TYPE OF INDUSTRY OR BUSINESS Office Of Mental Health
5. PLACE OF BIRTH I IIcknnw India
(CITY, STA'i'EiC&iNTRY IF NOT USA)
6. FATHER
A. NAME .I;::)grli~h ~h;::)ndr;::)
B. COUNTRY OF BIRTH India
7. MOTHER
A. MAIDEN NAME Krishna Srivastav::t
B. COUNTRY OF BIRTH Inrli;::)
8. NUMBER OF THIS MARRIAGE ?
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Montreal. Canada
(CITY, STATEICOUNTRY IF NOT USA)
16. FATHER
A. NAME Raiendra M ishra
B. COUNTRY OF BIRTHlndia
17. MOTHER
A. MAIDEN NAME Ravi Avasthi
B. COUNTRY OF BIRTHlndia
18. NUMBER OF THIS MARRIAGE 2
B. Dutchess
. (COUNTY)
o VILLAGE
D.
E.
13. A. AGEAA
14. EMPLOYMENT
A. USUAL OCCUPATION Domestic Enaineer
13.B. DATE OF BIRTH
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19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DEATH DIVORCE CIVIL ANNULMENT
1 1 0
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNUlJ,IENT (2) ~ DEATH B. HOW DID LAST MARRIAGE END? (3) r:1 DIVORCE (3) 0 ANNUlJ,IENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 07/?A / 2001 C. DATE LAST MARRIAGEENDED? 02 / 21 / 1992
MONTH . JlAY YEAR MONT'Lo DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES r!I NO . D. ARE ANY FORMER SPOUSE(S) ALIVE? CI YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 02/21/1992 New Delhi, India d' 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I, being duly sworn, depose and sa , that to the best of rny knowledge and be ief that the information proVided IS true and that I declare that no legal impediment exists
as to my right to enter into the ma state.
21. SIGNATURE OF GROOM. 22. SIGNATURE OF BRIDE. 12. a~h rn " ~ ha r ""~
USE CURRENT NAME
DATE 12/04/2002
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
This license authorizes the marriage in New York S bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within ew York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used ani for the purpose of a second or subs uent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
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{ SEAL }
'-..,-I
YEAR
TIME
MONTH
ATE 12/04/2002
NY 12590
STA
27. TYPE OF CEREMONY
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
IP
AM
03:08 PM 12
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) ./
o CITY cif.o TOWN 0:' t!r""VILLAGE*, J ~
PECIFY W,..."tL~ ~
CIVIL
NAME (PRINT)
SIGNATURE.
DOH-98 (11198)
NAME (PRINT)
SIGNATURE.
