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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
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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
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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 ,. ~