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COUNTY
XlXf/TOWN
DISTRICT
NUMBER
REGISTER
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Carl J.
I
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
Dutchess
Wappinger
1368
117
.~ yf~'z.loD
-.J
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Shakuntala(Annie)
FIRST MIDDLE
Ramcharan
CURRENT SURNAME
1. A. FULL NAME
Rohling
CURRENT SURNAME
11. A. FULL NAME
MIDDLE
FIRST
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
B BIRTH NAME. IF DIFFERENT
ROHLING
078-60-8566
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE)
D SOCIAL SECURITY NUMBER
12. RESIDENCE A. New J ersev 8. Essex
,STATE) ,COUNTY)
o CITY Xl TOWN = VILLAGE
Bloomfield
D. STREET ADDRESS 186 Hoover Ave.
115-48-0557
B Santa Clara
(COUNTY)
VILLAGE
C. CHECK ONE
AND
SPECIFY
07003
ZIP
3. A. AGE
30
Oct.
MONTH
27
Dec.
13.8. DATE OF BIRTH
13. A. AGE
MONTH
38. DATE OF BIRTH
14. EMPLOYMENT
4 EMPLOYMENT
A. USUAL OCCUPATION Analys t
B. TYPE OF INDUSTRY OR BUSINESS Fried, Frank,
15. PLACE OF BIRTH Manhattan, New York
(CITY. STATE/COUNTRY IF NOT USA)
Harris,
et al
A. USUAL OCCUPATION Attorney
8. TYPE OF INDUSTRY OR BUSINESS Portalwave,
5. PLACE OF BIRTH poughkeepsie, New
,CITY. STATE/COUNTRY IF NOT USA)
Inc.
York
16. FATHER
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7 MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE.
A. NAME Basdeo Ramcharan
B. COUNTRY OF BIRTH Guyana
17. MOTHER
Jerald R. Rohling
USA
McPherson
A. MAIDEN NAME Margaret Jonathan
B. COUNTRY OF BIRTH Guyana
First
Catherine
USA
First
18. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED 8Y
DIVORCE CIVIL ANNULMENT
DEATH
8. HOW DID LAST MARRIAGE END? (3) C DIVORCE
(3) 0 ANNULMENT
/ /
121= DEATH
8. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
,31 = ANNULMENT
/ /
(2) [; DEATH
C. DATE LAST MARRIAGE ENDED?
MONTH JAY YEAR
o 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 USAI SELF SPOUSE
MONTH OA Y YEAR
o 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) ICITY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST C 1ST
2ND 0 2ND
3RD [; 3RD
4TH 0 4TH
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true an.9 that I declare t.hat no legal impediment exists
as to my right to enter into the marriage s. ./ r:,.... j,~'
21. SIGNATURE OF GROOM ~ L - . 22. SIGNATURE OF BRIDE ~..r' .- ~(. ~, ~
USE CURRENT NA . USE CU .ENT NAME
Deputy Town Clerk D~E Julv 24, 2000
w
en
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CJ
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23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York St e 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.
i: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
Elaine H. Snowden, Town Clerk
DATE 7/24/00
NY 12590
9
22
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-.-'
NAME (PRIN
TIME
MONTH
DAY
YE:AR
MONTH
DAY
YE:AR
SIGNATURE
M~'cr~8~R
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
AM
12:30 PM
00
7
25
00
STATE
, 27 ~OF CEREMONY
o L. RELIGIOUS 1 = CIVIL
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B COUN.::J1;n:tff:>5
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF i:J TOWN OF ~GE OF
SPECIJ1!~~ear I-~
9 = OTHER. SPECIFY
NAME (PRINT)
SIGNATURE ~
[)()H.98 (1198)
NAME (PRINT)
SIGNATURE ~