No preview available
145 ] STATE OF NEW YORK r STATE FILE NUMBER I . Dutchess (THIS SPACE FOR STA TE USE ONL Y) COUI,TY DEPARTMENT OF HEALTH Wappinger ~J1ct q,/7~tl~ CITYiT01~ AFFIDA VIT, LICENSE and DISTRICT .:168 NUMBER REGISTER 145 CERTIFICATE OF NUMBER MARRIAGE Lo SUPPLEMENTAL FILE .-J FROM THE GROOM FROM THE BRIDE 1. A. FULL NAME Jason P. Cheung 11. A. FULL NAME Feng Yan Lai FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME 0- N , o lD N or- .:& .... ~ S:~ (D~ z'" Q) "0 0.. ,..13) I- zCD >- ~ ~ <( "'0) C :J:J _ ::>0 ~ LL !fa.. :3 LL ~ -~<( 04) Z ~~ 0:.... C ~~ " <.) w4) ~ ~CJ 0: o:.s: ~S "'0 ~ ,.. ~N ~OJ 0: w <.) w 0: w I ~ rJ) rJ) w 0:. o o <( >- ... u W 0- rJ) II: W '" ::; :J Z o Z " I- W W II: ?- m z :i 0: 0 ::> t= ~ <( 0: N ,.. Z rJ) ::;: ::> w ::;: 6 ,.. rJ) z <( ... U 0 u: ... rJ) o ;;: W 0 b '" z ;; B BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL. SEE REVERSE088 72 5340 D. SOCIAL SECURITY NUMBER -- 2. RESIDENCE A New York B. Dutchess (ST ATE) "'- (COUNTY) C. CHECK ONE CJ CITY D. TOWN 0 VILLAGE ~~~CIFY pougnkeepsle D. STREET ADDRESS oz soutn uale unve B. BIRTH NAME (MAIDEN NAME), IF OIFFERENT C. SURNAME AFTER MARRIAGE Cheung (OPTIONAL. SEE REVERSE) D. SOCIAL SECURITY NUMBER 12. RESIDENCE ANew York B Dutchess (STATE)!.t (COUNTY) C. CHECK ONE q CITY L.J TOWN 0 VILLAGE ~~~CIFY Pougl'lKeepsle D. STREET ADDRESSOZ soutn Gale Onve Z 120Ul IP "'" E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO /13 .l979 YEAR ZIP lZoUl ..". E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO 03 /23 /1976 DAY YEAR 13.B. DATE OF BIRTH 09 13. A. AGE 22 3. A. AGE26 3B. DATE OF BIRTH MONTH DAY MONTH 4. EMPLOYMENT A. USUAL OCCUPATION Sales Manager 5. :~::~::I:~U~~hhaW~n~S~: JOrk (CITY, STATE/COUNTRY IF NOT USA) 14. EMPLOYMENT A. USUAL OCCUPATION Unemployed B. TYPE OF INDU~.TRY OR BUSINESS 15. PLACE OF BIRTH l;h,na (CITY, STATE/COUNTRY IF NOT USA) 16. FATHER A. NAME Yingwang lai B. COUNTRY OF BIRTHcnlna 17. MOTHER A. MAIDEN NAME Huang Birui B. COUNTRY OF BIRTHChina lB. NUMBER OF THIS MARRIAGE 1 19. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DI{fRCE CIVIL A~ULMENT 6. FATHER A. NAME Kwan Cheung B. COUNTRY OF BIRTH (;nlna 7. MOTHER A. MAIDEN NAME Oy Yuk Chiu B. COUNTRY OF BIRTH China 8. NUMBER OF THIS MARRIAGE 1 9. PREVIOUS MARRIAGES A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY DIVlfCE CIVIL A~ULMENT DE6TH D~TH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT / / (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT / / (2) 0 DEATH C. DATE LAST MARRIAGE ENDED? C. DATE LAST MARRIAGE ENDED? 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 MONTH DAY YEAR 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 1 ST 0 0 1 ST 0 0 2ND 0 0 2ND 0 0 3RD 0 0 3RD 0 0 4TH 0 0 4TH 0 0 I, being duly sworn, depDse and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that nD legal Impediment exists as to my fight to enter into the marriage stat ~e :11 fA ~~,. / L ? 21 SIGNATURE OF GROOM ~ 22. SIGNATURE OF BRIDE ~ _ U1! __~ Lfll us URRENT NAME 09/10/2002 w en z w o ;:j 23. SUBSCRIBED AND SWORN TO BEF SIGNATURE OF TOWN OR CITY C ~ This license authorizes the marriage in New York Stat Relations Law ~11 to perform marriage ceremonies within o If checked, this license is to ~ 24 TOWN OR C'D' CLIiRK } NAME (PRINT) l;;jlona J. Morse {SEAL SIGNATURE ~_ 0 '-v-' M~'Mi!m@bush Rd, STREET I CERTIFY THAT I SOLEMNIZED THE MARRIAGE OF. THE PER. SONS NAMED ABOVE ON THE DATE AND AT THE TIME AND PLACE INDICATED. DATE of the bride and groom named above by any person authorized by New York Domestic w York State. THIS LICENSE VALID IN NEW YORK STATE ONLY. e used only for the purpose of a second or subsequent ceremony. 25. A. SOLEMNIZATION PERIOD BEGINS TIME MONTH YEAR TE 09/1 0/2002 er Falls, NY 12590 10:04 AM 09 PM ZIP STATE 27. TYPE OF CEREMONY 28. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. COUNTY.:AW Whe!!.S l~VIL RELIGIOUS OTHER, SPECIFY C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) o CITY OF <<TOWN OF 0 VILLAGE OF SPECIFY U ) Of P 11Lj e ,- 29. OFFICIANT NAME (PRINT) ::: V;;:~/:J~'~e '} { / ( .).~- ZIP 31. WITNESS TO CEREMONY. NAME (PRINT) :::J)(V\ l { l t {, C. Lf,(\ +-- SIGNATURE~ '"J::::>~.'1lA. t ,. ~