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COUNTY
JCJ[YfTOWN
OIST,RICT
NUMBER
REGISTER
NUMBER
Dutchess
Wappinger
1168
119
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
I STATE ALE NUMBER I
(THIS SPACE FOR STA TE USE ONL Y)
~ ~~VD
Lo SUPPLEMENTAL FILE -.J
FROM THE BRIDE
Ann M.
FIRST MIDDLE
Lawrence
CURRENT SURNAME
1. A. FULLNAME Refaat HaRRan AhOll ()11k,ql
FIRST MIDDLE CURRENT SURNAME
. 1. A. FULL NAME
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) /
o SOCIAL SECURITY NUMBER n _ a
2. RESIOENCEA. New York
(STATE!
~ CITY [J TOWN
Beacon
D STREETADDRESS 286 Main St. AJ)t. 4
C. CHECK ONE
AND
SPECIFY
B. Dutchess
(COUNTY)
o VILLAGE
C. CHECK ONE
AND
SPECIFY
ZIP
12508
12590
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES c: NO
/25 /1967
DAY YEAR
YES [J NO
/1975
YEAR
13. A. AGE 25
3. A. AGE
32
Mar.
MONTH
14. EMPLOYMENT
13.B. DATE OF BIRTH
3B. DATE OF BIRTH
DAY
4. EMPLOYMENT
A. USUAL OCCUPATION Receptionist
B. TYPE OF INDUSTRY OR BUSINESS Jeffrey Ginsberg DMD
15. PLACE OF BIRTH Shrub Oak. New York
(CITY. STATE/COUNTRY IF NOT USA)
16. FATHER
A. USUAL OCCUPATION Accounting
B. TYPE OF INDUSTRY OR BUSINESS une1l\Ployed
5. PLACE OF BIRTH (CI~7S~A~;COUNTRY IF NOT USA)
6. FATHER
A. NAME Hassan Abou Oukal
B. COUNTRY OF BIRTH Eygpt
7. MOTHER
A. MAIDEN NAME H,q 1 i,q ()llmer
B. COUNTRY OF BIRTH Eygpt
8. NUMBER OF THIS MARRIAGE F i r s t
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
Frederick
B. COUNTRY OF BIRTH USA
W. Lawrence
A. NAME
17. MOTHER
A. MAIDEN NAME Elizabeth M. Whelan
B. COUNTRY OF BIRTH USA
,B. NUMBER OF THIS MARRIAGE Fir s t
,9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE END? :31 [J DIVORCE
C. DATE LAST MARRIAGE ENDED?
:31 0 ANNULMENT
/ /
(2) C DEATH
B. HOW DID (AST MARRIAGE END? (3) 0 DIVORCE
v. DATE <..AST MARRIAGE ENDED?
3\ = ANNULMENT
/ /
21 C DEAl"
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH. DAY. YEAR) CITY STATE/COUNTRY. IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? = YES = NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
IMONTH. DAY. YEAR) (CITY. STATE/COUNTRY. IF NOT USA! SELF SPOUSE
C
w
en
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::::i
1ST 0 1ST
2ND 0 2ND
3RD 0 3RD
4TH 0 4TH
I, being duly sworn, depose and say. that to the best of my knowledge and belief that the mformalion I provided IS tL2nd that I de re that no legal Impediment exists
as to my right to enter Into the marna~e tat
21 SIGNATURE OF GROOM ~ ~~ 1A~ 22 SIGNATURE OF BRIDE ~
d ~
23. ~~J:T~~~DO~Nfo~O~:~~Bg~~i~E De ut Town Cle
This license authorizes the marriage in New York State of the bnde 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 subs uent ceremony.
~ 24. TOWN OR ~RK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) laine H~~en Town Clerk
{SEAL SIGNATURE ~ ~ \\. ~1Y1l\.\-&t:_ DATE 7/25/00 TIME M007NTH DAY YEAR MONTH DAY YEAR
MAILING ADDRESS 9: 15AM 26 00 09 23 00
~ PO Box 324 Wa in ers Falls NY 125 0 PM
s I A
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE 1M DAY Y 0 0 RELIGIOUS
DATE AND AT THE TI
PLACE INDICATED. 0 OTHER. SPECIFY
C
~
DATE July 25. 2000
by New York Domestic
25. B. SOLEMNIZATION PERIOO
ENOS AT MIDNIGHT ON:
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF VILLAGE 0;'- J I
SPECIFY W~PI~1."" ~
NAME (PRINT)
SlGNATURE~ ยท
