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COUNTY
CITYrrOWN
DISTFlICT
NUM~":ofl
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Amandeep S.
FIRST MIDDLE
Bhullar
CURRENT SURNAME
Dutchess
Wappinger
1368
134
I STATE FILE NUMBER I
(THIS SPACE FOR STATE USE ONLY)
/ qf11/0D
Lo SUPPLEMENTAL FILE -.J
FROM THE BRIDE
Manpreet K.
FIRST MIDDLE
A. FULL NAME
Dhaliwal
CURRENT SURNAME
11. A. FULL NAME
0-
N
B BIRTH NAME ,MAIDEN NAME), IF DIFFERENT
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 090 88 252
D. SOCIAL SECURITY NUMBER - - 1
2 RESIDENCE A. New York B. Dutchess
(STATE) y (COUNTY)
C. CHECK ONE = CITY ~ TOWN = VilLAGE
AND W.
SPECIFY appl.nger
D. STREET ADDRESS 50 Lake Oniad Drive ZIP 12590
Drive
ZIP 12590
C. CHECK ONE
AND
SPECIFY
Dhaliwal
066-90-1012
Dutchess
! COUNTY\
o VillAGE
C. SURNAME AFTER MARRIAGE
OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York
,STATE)
o CITY Xi TOWN
Wappinger
o STREET ADDRESS 53 Alpert
B.
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES IX! NO
Sept. / 19 /1979
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE' '-- YESXJ NO
13. A. AGE 19 13.B. DATE OF BIRTH March /29 /1981
MONTH DAY YEAR
3. A. AGE
20
3B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Cashier
B. TYPE OF INDUSTRY OR BUSINESS Convenience Store
5. PLACE OF BIRTH Punj ab, India
iCITY STATE COUNTRY IF NOT USA)
A. USUAL OCCUPATION Cashier / Student
B. TYPE OF INDUSTRY OR BUSINESS Convenience Store
15. PLACE OF BIRTH Pun i ab. India
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Ranj it Nagra
India
First
Kuldeep S. Bhullar
India
A. NAME Balwant S. Dhaliwal
B. COUNTRY OF BIRTH India
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Gurmeet Hare
India
First
18. NUMBER OF THIS MARRIAGE
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE "NO' ), = DIVORCE
C DATE LAST MARRIAGE ::NDED'
(21 = DEATH
3. ~C'N 010 LAS, 'JARRIAGE END? (3) C DIVORCE 31 = ANN0L'JENT
~. DATE c.AS, \1ARRIAGE ENDED? // /
MONTH JAY
D. ARE ~NY "CRMER SPOUSE(S) ALIVE? = YES = NO
20F ~RE\lIOUSLY :lIVORCED OR ANNUlED, PROVIDE THE FOLLOWING INFCRMAT'CN
DATE OF DECREE PLACE ISSUED AGAINST WHC'.I
MONTH. JAY. YEAi'll (CITY. STATE/COUNTRY, IF NOT USA\ SELF SPOUSE
2: = DE.;-"
(3) 0 ANNULMENT
/ /
V=.~R
YEAR
'.IONTH DAY
::I. ARE ANY FORMER SPOUSE:S. ALIVE? = YES = NO
'0. ,F PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATICN
DATE OF DECREE 'LACE ISSUED AGAINST WHOM
'MONTH. DAY, YEAR\ CITY S,o\TECOUNTRY. IF NOT USA) SELF SPOUSE
1ST 1ST
2ND 2ND
3RD ~ 3RD
4TH ; ~TH
I. oeing duly sworn, depose ana say. that to the best of my knowledge and belief that the InfDrmatlOn I provided is true and that I declare that no legal impediment eXIsts
as to my right to enter into the marnage state. J
21. SIGNATURE OF GROOM ~ . _"l 22. SIGNATLRE OF BRIDE ~ L
.
DATE
by New York Domestic
2000
w
en
z
w
o
::i
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any 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,
CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
ine H. Town Clerk
DATE 8/11/00
NY 12590
STATE
27. TYPE"OF CEREMONY
10
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON'
.-'-,
{ SEAL }
'-.t-I
NAME (PRINn
YEAR
MONTH
DAY
YEAR
TIME
MONTH
DAY
SIGNATURE ~
MAILING ADDRIi.S
PO Box j 4,
STREET
I CERTIFY THAT I SOLEMNIZEC
THE \1ARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICA TED.
:lP
10:30AM
PM
12
10
00
00
8
28, PLACE WHERE MARRIAGE OCCURRED
, :ytIVll
A. STATE NEW YORK B. COUNTY D r..aCUt; J
C. lOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF := TOWN OF ~LAGE OF
oC;
o [J RELIGIOUS
9 [J OTHER. SPECIFY
~ C<,~~, cf1:1- ~
NAME (PRINn ~ 5 . (O,.,)At. /)
SIGNATURE ~ t/.
MAiliNG ADDRE~S '
:z J t1 C( ANe/rj Pl ft1IrJhAlIe~J
STREET CITY OWN
30. WITNESS TO CEREMONY
NAME (PRINn C;; U J! C 1-1 H fA IV
TITLE
i/iUltlt :r",~r/(e
DATE o//fo
A I 'I
StATE
l'.4us
1.1 $ 9 b
. ZIP
31. WITNESS TO CEREMONY
NAME (PRINT) t'\ h
SPECIFY I.JAPII";~I.<: -fAu J
'bflIlLiu/AL
SIGNATURE ~
00H-9ll (1198)
SlGNATURE~