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COUNTY Dutchess
CITYTOWN W<3ppinger
~~~~~CRT 1 ~f)R
~0~I~J~R 1 ~~
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
M~JLIJjit S Sid~~hRENT SURNAME
A FULL NAME
FIRST
BIP,TH N~ME. IF DIFFERENT
C SURNAME AFTER MAR.RI~GE
IOPTIONAL . SEE REVERSE.I
o SOCIAL SECURIiI NU~IBER n46-R6-170?
Qllty)1P~~
(GUN )
VILLAGE
RESiDENCE A. N,~'t(E,v nrl<
c CHECK ONE 0 CITY LY'TOWN r
AND
SPECIFY Wt'lppinopr
o STREET ADDRESS 68 Carnaby street
ZIP 12~90
E IS RESiDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' [] YES cY' NO
MONW / 0;'''' / YE~~6
3 A
AGE 37
3B. DATE OF BIRTH
4 EMPLOYMENT
A. USUAL OCCUPATION
Prodllction Wnrker
I R M
B TYPE OF INDUSTRY OR BUSINESS
5 PLACE OF BIRTH lnrlit'l
ICITY, STATE COUNTRY IF NOT USAI
6 FATHER
A NAME Rajindpr Singh
B COUNTRY OF BIRTH I nrlit'l
7 MOTHER
A MAIDEN NAME Harbans Kaur
B COUNTRY OF BIRTH Inrlia
8 NUMBER OF THIS MARRIAGE ?
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
()
1
n
B HOW 010 LAST MARRIAGE END' 13) ~IVORCE (3) [] ANNULMENT (2, [J DEATH
C DATE LAST MARRIAGE ENOED? 00/ 26 / 2001
MONTH DA Y YEAR.
D ARE ANY FORMER SPOUSEIS) ALIVE? ~ES [J NO
10 IF PREVIOUSLY DIVORCED OR ANNULED PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY. STATECCOUNTRY, IF NOT USA) SELF SPOUSE
. -.
2 /:.., tJ /)
1\ J 0(
L [J SUPPLEMENTAL FILE
FROM THE BRIDE
Mt'lnrleer K Sirlhll
MIDDLE CURRENT SURNAME
~
11. A FULL NAME
FIRST
BIRTH NAME (MAIDEN NAME), IF DIFFcP,ENT Grewal
C SURNAME AFTER MAR,RIAGE Sidhll
(OPTIONAL - SEE REVERSEI
o SOCIAL SECURITY NUMBER n4R-78-9324
12 RESIDENCE A. Npw York B nlltr.hpS~
~IATEI ICOUNWi
C CHECK ONE D CITY CY'rOWN D VILLAGE
AND W .
SPECIFY ::lpplnoer
o STREET ADDRESS 68 Carnaby Street
IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE'
MO~ / ~W
ZIP 12590
13 A AGE 36
...J YES cY' NO
/ WA95
13.B. DATE OF BIRTH
14 EMPLOYMENT
A USUAL OCCUPATION PrndllctiOrl As-c;nr.\3tp
B TYPE OF INDUSTRY OR BUSINESS I R M
15. PLACE OF BIRTH Inrlit'l
(CITY. STATE COUf'.-:-RY IF NOT USA)
16. FATHER
A. NAME Terlor.1vm Grewal
B COUNTRY OF BIRTH lnrll<'l
17. MOTHER
A. MAIDEN NAME Gurjit Manget
B. COUNTRY OF BIRTH Inrli<:l
18 NUMBER OF THIS MARRIAGE ?
19 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
()
1
()
B HOW 010 LAST MARRIAGE END' 13, D~IVORCE (3) D ANNUL~IENT (2 D DEATH
C DATE LAST MARRIAGE ENDED? 0~/?6 / 2nn1
MONTH DAY YEAFI
D ARE ANY FORMER SPOUSE(S) ALIVE? O..(ES C 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
cll/
"
z
D cY 1ST 0'3/26/2001 Po"ghkee.psie, N~w York
[] [J 2ND
D D 3RD
[J [] 4TH
t of my knowledge and belief that the information I provided is true and that I declare that no legal impediment eXists
22 SIGNATURE OF BRIDE ~ r/\ 0. 11 (.;,1!J~[;'n N.t- c;:, '01 ~ LJ .
23 ~:tNSACTR~~~o&NT~~~OcfRN ~~yBg~;~~E DA TE 1 ? /17 noo 1
This license authorizes the marriage in New York groom named above by any person authorized by New York Domestic
Relations Law S 11 to perform marriage ceremonies wi in New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY
'= 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
0'3f26!2001 poughkeepsie, New York
~
21 SIGNATURE OF GP,OOM ~
LU
C/)
Z
LU
U
::i
~
{ SEAL }
'-.y-/
NAME (PRINT)
SIGNATURE ~ .
MAILING ADDRESS
Mnr~e~
r / I /7/':t
. _ //. t9.Lv~TE
STF.EET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INOICA TED
26
['
'-'
~
TIME
MONTH
YEAR
12
18
15 2002
28 PLACE WHERE MARRIAGE OCCURRED
A ST"-TE NEW YORK B COUNTY'J)~~
C LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
= CITY OF C TOWN OF ~lAGE OF
SPECIFY /AJMP&~Ut& ~
NAME (PRINT)
SIGNATURE ~