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COUNTY
~fTOWN
., DISTA1.T
NUMBER
REGISJER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
, MARRIAGE
FROM THE GROOM
Masood D.H.
FIRST MIDDLE
MIDDLE
......,.-..- ..----..
(THIS SPACE FOR STATE USE ONLY)
Dutchess
Wappinger
1368
159
/
L 0 SUPPLEMENTAL FILE
.J
FROM THE BRIDE
Nighat
FIRST
1. A. FULL NAME
Ansari
11. A. FULL NAME
Ebad
CURRENT SURNAME
CURRENT SURNAME
Q.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A New York
(STATE)
C. CHECK ONE D CITY X:J TOWN D
~~~CIFY Poughkeepsie
D STREET ADDRESS 4204 Cherry Hill Drive ZIP
12603
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
New York
,STATE)
C. CHECK ONE 0 CITY IX TOWN . ,
AND
SPECIFY Wappinger
o STREET ADDRESS 354 Town View Drive
Ansari
n/a
2. RESIDENCE A.
085-80-7404
B. Dutchess
(COUNTY)
VILLAGE
B.
Dutchess
COUNTY)
VILLAGE
ZIP 12590
OYES~NO
29 /1960
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13.A. AGE 27 13.B.DATEOFBIRTH Dec. /16
MONTH DAY
YESX:: ~o
/1972
YEAR
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE?
3. A. AGE 39 3B. DATE OF BIRTH Sept. /
MONTH
DAY
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION
Homemaker
A. USUAL OCCUPATION Physician
B. TYPE OF iNDUSTRY OR BUSINESS Vassar Bros. Hospital
5. PLACE OF BIRTH Karachi. Pakistan
(CITY. STATE/COUNTRY IF NOT USA)
B. TYPE OF INDUSTRY OR BUSINESS
15. PLACE OF BIRTH Karachi. Pakistan
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME Zubaidah Begum
B. COUNTRY OF BIRTH P akis tan
8. NUMBER OF THiS MARRIAGE First
16. FATHER
A. NAME
B. CDUNTRY OF BIRTH
17. MOTHER
Naimul Ebad
Pakistan
Waheed D.H. Ansari
Pakistan
Afroze Jahan
B. COUNTRY OF BIRTH P akis tan
18. NUMBER OF THIS MARRIAGE First
A. MAIDEN NAME
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS \lARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE END? 131 = DIVORCE
C. DATE LAST MARRIAGE ENDED?
i 3) D ANNULMENT
/ /
(2) 0 DEATH
21 = CE.~.,.....
B. HOW DID LAST MARRIAGE END? (3) u DIVORCE
C. DATE LAST MARRIAGE ENDED?
31 = ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? = YES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) iCITY. STATECOUNTRY. IF NOT USA) SELF SPOUSE
MONTH :-:AY YEAR
:J. ARE ANY FORMER SPOUSE(S) ALIVE? = YES = NO
20. F PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE GF DECREE PLACE ISSUED AGAINST WHCM
IMONTH. 'JAY. YEAR} (CITY. STATE/COUNTRY. IF NOT '"SA! 3ELF 3POUSE
w
rJ)
Z
w
o
::i
C 1ST
C 2ND
C 3RD
C 4TH
elief that the information I provided is true and that I declare that no legal impediment eXists
" , _1
Z2. SIGI'j,ATURE OF BRIDE ~ ttJ~~ f~~~
. USE CURRENT NAME
Deputy Town Cl rk 9/8/00
DATE
This license authorizes the marriage in New York State 0 the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
::J 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(PRINn~ Ela~ne H. Snowden, Town Clerk
{SEAL SIGNATURE ~ ~ ~inA.,d,h..... DATE 9/8/00 TIME MONTH DAY YEAR MONTH DAY
MAILING ADDRESS 11.30AM
'-v-I PO Box 324 Wa in ers Falls, NY 12590 . 9 9 00 11 7
I PM
26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
IME MO. DAY YEAR 0 III .RELlGIOUS
GO 9 0 OTHER. SPECIFY
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, that to
as to my right to enter into the marriage state.
o
o
o
21. SIGNATURE OF GROOM ~
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK.
25. B. SOLEMNIZATION PERiOD
ENDS AT MIDNIGHT ON:
YEAR
00
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY] ~T't1 €.s_
1 = CIVIL
3:;;.e 01 Jb
~~tf~~~~T fg4\ 1\ H / M A, M f H-t E ~
SIGNATURE. L.-~ A. tv\~
MAILING ADDRESS -
103 S'ool( ~llL ~DAJ wA PPIW6t ,tV fAtts NY
STREET CITYfTOWN STATE
30. WITNESS TO CEREMONY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 1; TOWN OF = VILLAGE OF
('0 u.c..M KE E'~ Sl€
TITLE
(Q,a.,i
l1
'~ J J b 100
,
I~S~O
SPECIFY
DATE
NAME (PRINn
SIGNATURE.
DOH-98 (11118)
ZIP
31. WITNESS TO CEREMONY
ZI./I.
idYl
NAME (PRINT)
SIGNATURE .