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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
GrA!iI~~ n::lvirl ~1Jp'~le
I D~ C~R ENTSURNAME
COUNTY Dutchess
CITYfTOWN Wappinger
~~~:~c~ 1368 .
~~~I:~~R 87
L A. FULL NAME
FIRST
B- BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)132-42 7660
D. SOCIAL SECURITY NUMBER _ ____ - ____
2. RESIDENCE A. NY B. nlltr.hess
lSTATE) (COUNTY)
C. CHECK ONE 0 CITY lil:J TOWN 0 VILLAGE
~~~CIFY Fast Fishkill
D. STREET ADDRESS 3 Beverly Court ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YESo(] NO
3. A. AGE 60 3B. DATE OF BIRTH n7 / nfl /1950
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Attnrney
B. TYPE OF INDUSTRY OR BUSINESS Lyons & Supple
5. PLACE OF BIRTH Yc~~s~~~~do~Y IF NOT USA)
6. FATHER
A. NAME .Inhn I en SlJpple
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy Jane Breen
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) l'!'l'DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 03/ 04 / 2010
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? [<(YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
03/04/2010 Poughkeepsie. Ny
DEATH
o
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and sa
as to my right to enter into the
~
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Lisa Kim Yi
MIDDLE
~
1 L A. FULL NAME
FIRST
CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE Supple
(OPTIONAL - SEE REVERSEI-73 82 4479
D. SOCIAL SECURITY NUMBER ::> - -
12. RESIDENCE ANY BPutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFYEast Fishkill
D. STREET ADDRES~ Beverly Court
ZIP 12533
o YES~ NO
)957
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE52 13B.DATE OF BIRTH 10 )1"3
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Yoga Instructor
B. TYPE OF INDUSTRY OR BUSINESS Health Care
15. PLACE OF BIRTHFresno, Ca
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Harry Dong Chan Yi
'B. COUNTRY OF BIRnJ.J S A
17. MOTHER
A MAIDEN NAME Sallie Dunn
B. COUNTRY OF BIRTJJ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? /,(
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
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1ST
2ND
3RD
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This license authorizes the marriage in New York State of 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.
o If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24. TOWN OBJ:;II'!' J:;LERIL_ 25. A. SOl;EMNIZATION PERIOD BEGINS
} NAME (PRINT) Jo
{TIME MONTH YEAR MONTH
SEAL SIGNATURE ~
'-v-' MAI2(UHidal~b 02:49~~ 07 16 2010 09 13 2010
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
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SIGNATURE~
DOH-98 (09/2009)
07/15/2010
YEAR
1 rst CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~
LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~ TOWN OF 0 VILLAGE OF
SPECIFY ~4 S. -t- F', ~ b.kilt
NAME (PRINT)
SIGNATURE~