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COUNTY Dutchess
CITY/TOWN Wappinger
B~~~~CRT 1 ~n8
~G~'~~~R R
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Gonn H r.bellon
MIDDLE CUi1i\ENT SURNAME
I
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
(lEnt
'3 ^
I ~ ,J., -('1\
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
I(}('lnn~ 7hllo/1ong r.hpn
MIDDLE CURRENT SURNAME
--.J
1. A FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C SURNAME AFTER MARRIAGE Chel Ing
(OPTIONAL' SEE REVERSE)
D SOCIAL SECURITY NUMBER 612-07 -0720
12. RESIDENCE A. N ('irATE) B q~t~twss
C CHECK ONE D CITY OfrOWN D VILLAGE
AND \^J .
SPECIFY v v ('lpp,nopr
D STREET ADDRESS 35 Reggie Orive ZIP 12590
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' DYES lY' NO
13 A AGE 28 13.B. DATE OF BIRTH MOOO / JA~ / W.:p
14. EMPLOYMENT
A. USUAL OCCUPATION Bookkeeper
8. TYPE OF INDUSTRY OR BUSINESS V~IIE!Y Vi~tt=l
15. PLACE OF BIRTH ~t=lntnn ~hint=l
(CITY, STATE/COUNTRY IF NOT USA)
16 FATHER
A. NAME Jian Han Chen
8. COUNTRY OF BIRTH China
17. MOTHER
A. MAIDEN NAME Xiao Mei Li
B. COUNTRY OF BIRTH China
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
o SOCIAL SECURITY NUMBER 059-80-9279
2. RESIDENCE A N v B.
(sill TEl
C CHECK ONE D CITY rJl'TOWN D
AND W .
SPECIFY ~pplnopr
o STREET ADDRESS 35 Reggie Drive ZIP 1/590
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE' DYES r!I' NO
MONtP / DW3 / YEt~7
Q~~ess
VILLAGE
3 A AGE 26
3B. DATE OF BIRTH
4 EMPLOYMENT
A USUAL OCCUPATION Flpdri~e' Fnoinppr
8. TYPE OF INDUSTRY OR BUSINESS r,pm~ I R M. Pnk
5. PLACE OF BIRTH ~t=lntnn ~hin~
(CITY, STATE/COUNTRY IF NOT USA)
6 FATHER
t- A. NAME Tim Chi In Chellng
~ B. COUNTRY OF BIRTH ~hina
C 7 MOTHER
u: A MAIDEN NAME K'Nai Chun Lam
u.
<t 8. COUNTRY OF BIRTH China.
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
o
o
o
o
o
o
(2) q DEATH
B HOW 010 LAST MARRIAGE END' (3) 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
(2) D DEATH
B. HOW 010 LAST MARRIAGE END' (3) D DIVORCE
C DATE LAST MARRIAGE ENDED?
(3) D ANNULMENT
/ /
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
l8T D D l8T D D
2ND D 0 2ND D [J
3RD D 0 3RD D D
4TH D D 4TH D D
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 that no legal impediment exists
as to my right to enter into the marriage state. . / ~/,.Il . //
21 SIGNATURE OF GROOM ~ / l'"t GNATURE OF BRIDE ~ a.9tf'l1./!L-'<:?7~~q~~
USE r 1 USE CURRENT NA;d-'
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23 SUBSCRIBED ANO 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 !ill 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 secDnd or subsequent ceremony.
24 TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
DATE
01/11nm2
by New York Domestic
~
{ SEAL}
'-v-'
MONTH
DAY
YEAR
MONTH
YEAR
TIME
08:3~M
PM
200
03
12 2002
01
12
STR
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED
l~L
28 PLACE WHERE MARRIAGE OCCURRED
A STATE NEW YORK 8. COUNT~~Tt~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY). ./
D CITY OF 0 TOWN OF I!("VILLAGE ~ /1
SPECIFY /,UI((Jp, 'hi" t Jt.l.~
29. OFFICIANT
NAME (PRINT)
STREET CITY/TOWN
30. WITNESS Tt C EMONY
NAME (PRINT) .rAR /,.vJc {)-/~VNfr
SIGNATURE~ .~ U d~
DOH-98 (11/98)
e..