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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
..", CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Satwinder
A I
27. TYPE OF CEREMONY .---
o 0 RELIGIOUS 1 ~l
COUNTY Dutchess
~/TOWN ,Wappinger
2~=fr 1368
~5~~~R 101
1. A. FULL NAME
Sinp;h
CURRENT SURNAME
FIRST
MIDDlE
B BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL . SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. New York
(STATE!
C. CHECK ONE C CITY Xl TOWN 0
~~~CIFY Wappinp;er
D. STREET ADDRESS 510 Maloney Road. K-6 ZIP 12603
.t'oughkeeos1.e
E. IS RESIDENCE WITHiN UMITS OF CITY 'dR INCORPORATED VilLAGE? c.J YES X NO
3. A. AGE 24 3B. DATE OF BIRTH Oct. /23 /1974
MONTH DAY YEAR
060-88-2065
B. Dutchess
(COUNTY)
VilLAGE
4. EMPLOYMENT
A. USUAL OCCUPATION Assis tant Manager
B. TYPE OF INDUSTRY OR BUSINESS Citco Gas Mart
5. PLACE OF BIRTH Rohti, India
(CITY. STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
Gurmukh Singh
India
B. COUNTRY OF BIRTH
7. MOTHER
Surinder
India
8. NUMBER OF THIS MARRIAGE Second
Kaur
A. MAIDEN NAME
B. COUNTRY OF BIRTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
One
DEATH
B. HOW DID LAST MARRIAGE END? 131 ~ DIVORCE (3) 0 ANNULMENT (21 C DEATH
C. DATE LAST MARRIAGE ENDED? April / 6 / 2000
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNUlED, PROVIDE THE FOllOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) I CITY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
4/6/00 Dutchess Co.. NY ~ X
~
{ SEAL}
'-v-'
NAME (PRIN
SIGNATURE ~
MAILING ADORE
P.O. Box
ST E
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
29. OFFICIANT
NAME (PRINT)
~ ~~:~~t-
r
STATE FILE NUllBER
(THIS SPACE FOR STATE USE ONLY)
"I
/ ;1}1jCi
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kanwaloreet
FIRST MIDOLE
-1
Dhaliwal
CURRENT SURNAME
fl. A. FUll NAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
12. RESIDENCEA. New York
(STATE)
o CITY 10 TOWN
Wappinp;er
D. STREET ADDRESS 510 Maloney Road.
Singh
090-88-4282
C. CHECK ONE
AND
SPECIFY
B Dutchess
(COUNTY)
~ VilLAGE
K -6 ZIP
12603
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Xl NO
13.A. AGE 20 13.B. DATE OF BIRTH Oct. / 27 /1979
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Server
B. TYPE OF INDUSTRY OR BUSINESS Home Town Buffet
15. PLACE OF BIRTH Badhni Kalan. India
(CITY. STATE/COUNTRY IF NOT USAI
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Gurmail Dhaliwal
India
Baljeet Kaur
India
First
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? (31 C DIVORCE
C. DATE LAST MARRIAGE ENDED?
,3) :::J ANNULMENT
/ /
(21 C DEATH
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? eYES = NO
20. IF PREVIOUSLY DIVORCED OR ANNUlEO. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE iSSUED AGAINST WHOM
(MONTH. DAY. YEAR) (CITY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
YEAR
:::;
::J
TIME
MONTH
DAY
YEAR
MONTH
YEAR
!0:45AM
PM
6
27
00
8
25
00
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY~~fS
C. lOCATION OF CEREMONY
(CHECK ONE AND ~Y)
o CITY OF ~WN OF 0 VIlLAGE OF
SPECIFY
SIGNATURE .