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COUN!y Dtlt.ch~!;!;
~OWN W~pp;ng~T
~~~~fJ 13 68
~5~I~J~R 18-S
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
s.
MIDDLE
I STATE ALE NUMB!:R
(THIS SPACE FOR STATE USE ONLY)
/ ,0\,,,,\ofJ
L u SUPPLEMENTAL FILE ~
FROM THE BRIDE
1. A. FULL NAME
Chinmay
FIRST
07.a
CURRENT SURNAME
11. A. FULL NAME
N.qvnppr
FIRST
K
MIDDLE
S.qnrlntt
CURRENT SURNAME
B. BIRTH NAME, MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE 07..q
10PTIONAL . SEE REVERSE)
D. SOCIAL SE.:URITY NUMBER 01 R- 7 R-R 144
12. RESIDENCEA. Connecticut B.
ISTATE) i.COUNTYI
c. CHECK ONE JC] CITY D TOWN VILLAGE
AND
SPECIFY Danbury
D STREET ADDRESS ZIP 06 R 1 1
0-
N
BIRTH NAME. iF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
o SOCIAL SECURITY NUMBER 01 7 - 8 2 - 13 1 0
2. RESIDENCEA. New York 3. Dl1rCnpQq
ISTATEI (COUNTY)
C CHECK ONE :: CITY:lt: TOWN = VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 21A Hudson Harbor Dr. ZIP 12601
.
S OF CITY OR INCORPORATED VILLAGE' ~ YES = NO
13.8. DATE OF BIRTH .T111v /01 /lg78
MONTH DAY YEAR
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E. IS RESIDENCE WITHiN LiMITS OF CITY OR INCORPORATED VILLAGE'
3. A AGE ? ':\ 3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Sof tware Engineer
B. TYPE OF INDUSTRY OR BUSINESS IBM
uYES~NO
13. A. AGE 22
14. EMPLOYMENT
5. PLACEOFBIRTH R.qT'nrl.q Tnrli.q
(CITY. STATEiCOUNTR~ IF NOT USA'
A. USUALCCCUPATION Full-time Student
B. TYPE OF iNDUSTRY OR BUSINESS SCSU
15. PLACE OF BIRTH New Delhi ~ Ind; a
ICITY. STATEiCOUNTRY IF NOT USA)
16. FATHER
A. NAME Iqbal S. Sandhu
B. COUNTRY OF BIRTH India
17. MOTHER
A. MAIDEN NAME Narinder Bhamrah
3. COUNTRY OF BIRTH IncH a
18. NUMBER OF 7HIS MARRIAGE 1<'; T'Qr
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
6. FATHER
to-
=>
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LL
LL
<(
A. NAME Sudhirkumar J. Oza
B. COUNTRY OF BIRTH India
7. MOTHER
A. MAIDEN NAME Pr.qf1111~ P~rpl
B. COUNTRY OF BIRTH India
8. NUMBER OF THIS MARRIAGE Fir s t
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNUL\lENT
DEATH
2 = :E,H~
B HOW DiD LAST MARRIAGE END? ,3\ = DIVORCE
C. DATE LAST MARRIAGE ENDED?
31 0 ANNULMENT
/ /
i21 C DEATH
3. HOW DID ~~ST MARRIAGE END' (31 C OIVORCE 3\ = ANNULMENT
v DATE LAST \lARRIAGE ENDED? / /
\.40NTH )A Y
~. ARE .ANY =ORMER SPOUSEIS) ALIVE? = YES = NO
20. F :",EVIOUS~Y ~IVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATiON
DATE JF DECREE PLACE ,SSUED AGAINST WHOM
MONTH JAY vEARI ICITY. STATE-COUNTRY. IF NOT USA! SELF SPOUSE
'fEAR
YEAR
MONTH OA Y
D. ARE ANY FORMER SPOUSE(S) ALIVE? = vES::J NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUE: AGAINST WHOM
(MONTH. DAY. VEAR\ CITY. STATE COUNTRY F NOT USAI SELF SPOUSE
1ST
2ND
3RD
4TH
I. being duly sworn. depose and say, that
as to my right to enter into the marriage sta
21. SIGNATURE OF GROOM ~
~
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23. SUBSCRIBED ANt! SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in Ne York State of the bri and groom named bove by ny person authorized
Relations Law ~11 to perform marriage ceremonies within 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 OITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT~-EJ a;~.,J4-_Snp.lIldeD. 'l'OtJT1 Cler:k
{ SEAL SIGNATURE~d(l_u:",' ~"':::::-;;LI.O",.A...ll DATE g/?F.!OO
MAILING ADDRESS . AM
~ P.O.Box 324 Wapp;ngers F~ll~. NY 12~gO 12:05PM 09
STREET CITYfTOWN :!TATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER. ~ ~
SONS NAMED ABOVE ON THE TIME Me DAY YEAR RELIGIOUS 1 jioo'ClVIL
DATE ANO AT THE TIME
PLACE INDICATED
11
25
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
27
00
28. PLACE WHERE MARRIAGE OCCURRED
OTHER. SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF []
SPECIFY IIJ
SIGNATURE ~
OOH-98 (1/98)
NAME (PRINT) ·
SlGNATURE~ ·