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COUNTY Dutchess
CITY/TOWN Wappinqer
1368
53
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Bin Jia
;:) I A II:. t'ILC NUMtU:.M
(THIS SPACE FOR STATE USE ONL Y)
<<j~d
<" /)
!J -I!) - tJ~
DISTRICT
NUMBER
REGISTER
NUMBER
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
~~ngyan Wa~U~RENT SURNAME
..J
A FUll NAME
11. A. FUll NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
B BIRTH NAME. IF DIFFERENT
BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Wang
(OPTIONAL' SEE REVERSE)
o SOCIAL SECURITY NUMBER 485-29-6602
12 RESIDENCE A. N Y B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE D CITY D ""fOWN D VILLAGE
~~~CIFY Fishkill
o STREET ADDRESS 56 Town View Drive
Wapp~ngers r'alls
IS RESIDENCE WITHIN L1MrrSOF crt1 OR INCORPORATED VilLAGE?
13 A. AGE ?~ 13.B. DATE OF BIRTH 11 /
MONTH
12590
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER
RESIDENCE ANY
(STATE)
C CHECK ONE D CITY
~~~CIFY Fishkill
o STREET ADDRESS 56 Town View Drive ZIP 12590
IS RESIDENCE WITHIN L1MITs\olr~1? W&Fif:&AJ'D~L*Jh DYES d"" NO
3 A AGE 30 3B. DATE OF BIRTH O? / ?1 / 197
MONTH DAY YEAR
068-88-3988
B Dutchess
(COUNTY)
D""TOWN D VILLAGE
ZIP
D YES D~NO
OR /197R
DA Y YEAR
14. EMPLOYMENT
4. EMPLOYMENT
A. USUAL OCCUPATION
Software Engineer
IBM COrD-
A. USUAL OCCUPATION Student
B. TYPE OF INDUSTRY OR BUSINESS Maharishi University
15. PLACE OF BIRTH Lanzhou, China
(CITY, STATE/COUNTRY IF NOT USA I
B. TYPE OF INDUSTRY OR BUSINESS
5 PLACE OF BIRTH Jinan. China
(CITY, STATE.COUNTRY IF NOT USA)
16 FATHER
6 FATHER
A. NAME Guanghua Wang
B. COUNTRY OF BIRTH China
A NAME Keliang Jia
B COUNTRY OF BIRTH China
7 MOTHER
A MAIDEN NAME YlIsong I in
B COUNTRY OF BIRTH China
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
17. MOTHER
A. MAIDEN NAME MeilinQ Zhu
B. COUNTRY OF BIRTH China
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
B HOW DID LAST MARRIAGE END? (3) D DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
1ST
2ND
3RD
4TH
I, being duly sworn, depose and sa1'..1l)at tP. the
as to my right to enter into the marnage ;t .
21 SIGNATURE OF GROOM Ii>
D D 1 ST D D
D D 2ND D C
D D 3RD C 0
D D 4TH n 0
my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
~h'~? t~~
-:::." /09/2002
w
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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 State of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D 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) GIO~,i ) TIME MONTH
SEAL SIGNATURE ~ /' / DATE 05/09/200
'-v-" MAIL~B ~CfdFebush in r Falls NY 12590 AM 05
STREET CITYCTOWN STATE ZIP 12 :OOM
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
by New York Domestic
RELIGIOUS
~IVIL
28 PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNT~:)L,L'-k t,l"4
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
29 OFFICIANT
NAME (PRINT)
D CITY OF XTOWN OF D VILLAGE OF
SPECIFY I ~ Df; ~e ('
~ I
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