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1. A. FULL NAME
STATE OF NEW~YORK
DEPARTMENT OF HEALTH
AFFIDA VIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Haodong
FIRST
Hong
CURRENT SURNAME
I
STATE ALE HUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
~ ~~"OWN Wappinger
~:J~~9J 13 6 8
~5~~~R 59.
/~\401)
L 0 SUPPLEMENTAL FILE
-.l
FROM THE BRIDE
Xiao Jing
FIRST
Qiu
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
MIDDLE
0-
N
B BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SDCIAL SECURITY NUMBER
12. RESIDENCEA. New York B Dutchess
(STATE) . (COUNTY)
o CITY Xl TOWN 0 VILLAGE
Wappinger
D. STREET ADDRESS 30 DeGarmo Hills Rd. ZIP 12590
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. New Yo r k
(ST~E, ;JJ;
C. CHECK ONE _ CITY i9 TOWN :::]
AND W'
SPECIFY app~nger
30 DeGarmo Hills
Qiu.
110-82-8597
105-76-6009
Dutchess
(COUNTY)
VILLAGE
B.
C. CHECK ONE
AND
SPECIFY
3. A. AGE
29
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES X:J NO
13.A.AGE 25 13.B.DATEOFBIRTH Aug. /25 /1974
MONTH DAY YEAR
3B. DATE OF BIRTH
4 EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION Restaurant Manager
B. TYPE OF INDUSTRY OR BUSINESS Q' s Garden
5. PLACE OF BIRTH Zhej iang, China
(CITY. STATE/COUNTRY IF NOT USA)
A. USUAL OCCUPATION 'Software Engineer
B. TYPE OF INDUSTRY OR BUSINESS IBM Corp.
15. PLACE OF BIRTH Zhe; iang. China
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
8. NUMBER OF THIS MARRIAGE
16. FATHER
A. NAME
B. COUNTRY OF BIRTH
17. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Bozhuang Qiu
China
Ke Bo Hong
China
Peng Lan Xu
China
First
Huang Ju Hu
China
First
18. 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 END? (31 LJ DIVORCE 13) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? :J YES ::: NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR I iCITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) C DEATH
MONTH DAY YEAR
D ARE ANY FORMER SPOUSE(S) ALIVE? iJ YES C NO
20. 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
1ST
2ND
3RD
4TH
I. being duly sworn, depose and
as to my right to enter into the
21. SIGNATURE OF GROOM ~
o
o
o
o
o
o
c []
[] []
0 []
W
tn
Z
W
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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 S ate of the bride and groom named above by any person authorized
Relations Law ~11 to perform marriage ceremonies within New York Slate. 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 OR ER~ine_ H. nowden, Town Clerk 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
TIME MONTH DAY YEAR
SEAL SIGNATURE ~ DATE 5/8/00
'-v-I M~I(f~8~ Falls, NY 12590 8:30 AM
P PM
00
DATE
May 8, 2000
by New York Domestic
25. B. SOlEMNIZATION PERIOD
ENOS AT MIDNIGHT ON:
MONTH
DAY
YEAR
5
9
00
7
7
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME ANO
PLACE INDICATED.
A
27. TYPE OF CEREMONY
o ~ RELIGIOUS
9 0 OTHER, SPECIFY
A. STATE NEW YORK B. COUNTY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
!::S~fr/~crtf r;;;1,rei
,(/~~ )/. (oo,^_
y,'
28. PLACE WHERE MARRIAGE OCCURRED
1 C CIVIL
/vi ~ ,jftl/l
29. OFFICIANT
NAME (PRINT)
ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~