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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Atilla
COUNTY
'=IIYfTOWN
DISTRICT
NUl illER
RS3ISTER
NUMBER
Dutchess
Wappinger
1368
167
, A. FUll NAME
Cansiz
FIRST
MIDDLE
CURRENT SURNAME
ll.
N
3. BIRTH NAME. IF DIFF..RENT
C. SURNAME AFTER IlARRIAGE
(OPTIONAL. SEE REVERSE) /
D. SOCIAL SECURI1\' NUMBER n a
2. RESIDENCE~. Germany B.
.STA~ (COUNTY)
C. CHECK ONE ]L CITY C TOWN .C VILLAGE
~~~C;FY Hannover
o STRES~DDRESS Mathildenstr 15
". IS RESIDENCE WITHiN UMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 2 9 3B. DATE OF BIRTH OC t . /
ZIP 30451
XYES=~
12 /1970
~AY YEAR
MONTH
4. EMPLOYMENT
A. USUAL OCCUPATION S tuden t
B. TYPE OF INDUSTlRY OR BUSINESS Hannover. Germany
5. PLACE OF BIRTH Hannover. Germany
.CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
, . MOTHER
Ihsan Cansiz
Turkey
Barbel Janke
Germany
8. NUMBER OF TIiIS MARRIAGE First
A. MAIDEN NAME
3. COUNTRY OF 31RTH
9. PREVIOUS MARRIAGES
A. NUMBE;:1 OF PRE'iIQUS MARRIAGES WHICH ENDED BY
DIVORCE C;VIL ANNULMENT
DE.~TH
3 ~OW DID LAST MARRIAGE END? 31 = DIVORCE
~. DATE CAST MARRIAGE ENDED?
,31 C ANNUUMENT
/ /
21 = wE.~r~
'dONTH DAY '(EAR
D. ARE .ANY =ORMER SPOUSE(S) ALiVE' = YES = NO
'0. F PREVIOUSLY DIVORCED OR ANNULED. PROVIDE -:-HE FOLLOWING INFORMATION
~A TE OF JECREE PLACE ISSUED ~GAINST WHOM
. MONTH. JAY. YE,ARI CITY. STATE COUNTRY. ;F 'lOT USA) SELF SPOUSE
r
STATE FLE ..-at
(THIS SPACE FOR STATE JJSE eN. VJ
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Hitay Kaltalioglu
FIRST MIDDLE CURRENT SURNAME
I
,--J
11. A. FULL 'lAME
B. BIRTH NAME :MAIDEN NAMe. IF DIFFERENT
~. SURNAME AFTER MARRIAGE Cans iz
,OPTIONAL. SEE REVERSE) I
J. SOCIAL ::<CURI1\' NUMBER n I a
12, 'lESIDENCE A. Germany B.
IST~) COUNTY'
J. CHECK:NE ill CITY :: TOWN - VilLAGE
~&;FV Hannover
J STREE"AODRESS Mathildenstr 15 :? 30451
_ is RESiDENCE WITHIN LIMITS OF CITY OR INCORPORATED.l~GE' ~ YES = .'10
13.A.AGE 34 13.B.DATlEOFBIRTH June /21 /1966
...cNTH ::A Y~EAA
14. EMPLOYMENT
A. USUAL XCUPATION Tax Preparer
B. TYPE OF INDUSTRY OR BUSINESS Hannover , Germany
15. PLACE OF ClIRTH Ankara , Turkey
(CITY. ST A TECOUNTRY IF NOT USA)
16. FATHER
A. NAME Ulken Kal talioglu
9. COUNTRY OF BIRTH Turkey
17. MOTHER
A. MAIDEN NAME Erika Alphei
3. COUNTRY OF BIRTH Germany
18 :'UMBE;:1 CF 'HIS MARRIAGE Firs t
. 9. ~qEVIOUS I.IARRIAGES
. 'lUM8E" OF PREVIOUS MARRIAGES WHICH ENCE: 3Y
JIVCRCE CIVIL ANNUlME~7
JE.UH
3. -<JW:O _..s, ~ARRIAGE "NO? 31 c::: w'VORCE
. JATE _AS, MARRIAGE ENDED?
= .l.NNL'l..M2;-
2~ = ::.~~-
\lCNTH
: ARE ":-,Y =ORMER SPOUSE,S) ALIVE? = YES
:.~..,
:'0
'::A~
20. F ~qE'i;C~SLY DIVORCED OR ANNUlED. .~ROVIDE --E ='ClLOW""G NFCRMA7:CN
JAT: :F JECREE PLACE SSUEO 'GAINS7NfoCM
\!ON,- JAY. YEARl . CITv STATECCUNTRY :F '<C- _SAI SELF SP'J~SE
1ST 1ST
2ND 2ND
3RD 3RD
4TH 4TH
I. oelng duly sworn. deoose and say, thaI to the besl of my knowledge and belief thaI the :nrormanon i prOVided is true and that I declare mal ~o legllJ ,mpeaiment eXIsts
as to my righl to enter InlO the marriage stat?: J i ... d .J.~' .
21 SIGNATURE OF GROOM ~ I 22. SiGNA'T'URE OF BRIDE ~ ~;I-~. I"avu /1
I ~RE.'" '<AME "
23. SUBSCRIBED ANOSWORN TOBEFORE"'E "<..tt.-- Dep.uty Town Clerk ~A= Sept. 11, "_..OOl
SIGNATURE OF TOWN OR CITY CLERK ~ ..- - ,~
This license authorizes the marriage in New York St e of the bride and groom namea above by any person authorizea by New York Domesnc
Relations Law ~11 to perlorm marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked. this license is to be used only tor the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS 25. B. ~~c:;o
{ } NAME IPRIN~Elaine H. Snowden. Town Clerk TIME MONTH DAY YEAR MONTH DAY YEAR
SEAL SIGNATURE ~~ILe L~~"'I\"'.rl#.1 CATIE 9/11/00
MAILING ADDRESS - AM
'-v-I PO Box 324 Wa in ers Falls NY 12590 1 :30 PM 9 12 00 11 10 00
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28. PLACE WHERE MARRIAGE OCCL:RRED
A. STATE NEW YORK 3. couN))'(]~
C. lOCATION OF CEREMONY / ,y'"
(CHECK ONE AND SPECIFY) .
iJ CITY OF :J TOWN OF :Y"VUAGE OF
SPECIFY fA)I'rPPJM"~ ~
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON
DATE AND AT THE T1
PLACE INDICATED.
26. SOLEMNIZATION OCOURRED
I AY
27. TYPE OF CEREMONY
o = RELIGIOUS , ~IL
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