015
+
....
z
w
(j)
W
III
o
...J
:;,
o
I
(j)
Z
o
;::
"
a:
....
(j)
C;
w
a:
w
~
a:
a:
"
::<
u.
o
w
~
<..l
u:
;::
a:
w
<..l
w
a:
w
I
~
(j)
(j)
w
a:
o
o
"
it
C3
W
0-
(j)
~
:>
<(
c
wi!
"'u..
~<(
~
;t
o
~
C3
a:'
w
lD
::;
::>
z
o
z
"
t-
W
W
a:
t-
OO
+
tE:i:Z W
~~~
~~~ !;;
....WZ ""
~d~ 0
~~g u:
~~~ ~
[fO(j) W
0....>-
lii~;3 0
b~U)
Z:J~
COUNTY Dutchess
CITYrrOWN Wappinger
DISTRICT 1 368
NUMBER
REGISTER 1 5
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason Matthew Berban
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
"I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Ashley Lyne Johnson
MIDDLE CURRENT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)454_79_3112
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) J. (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN U VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 29 South MeSler Ave, ZIP 1259U
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO
04 / 09 / 1983
MONTH DAY YEAR
3B. DATE OF BIRTH
01
YES 0 NO
)1'987
YEAR
13. A. AGE 22
3. A AGE 25
3B. DATE OF BIRTH
MONTH
w
!;;:
t-
oo
4. EMPLOYMENT
A USUAL OCCUPATION Retail Store Manager
B. TYPE OF INDUSTRY OR BUSINESS Retail
5. PLACE OF BIRTH San Antonio, Texas
(CITY, STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME James Albert Berban
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Rose C. Leslie
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUgRY OR Bl!SI,SS CIA
15. PLACE OF BIRTH IVlidlana, exas
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A NAME Monte Ray Johnson
'B. COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Betty Lynn Stewart
B. COUNTRY OF BIRTH USA
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEbTH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH
C. DATE LAST MARRIAGE ENDED? / (.
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
~
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT
/ /
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
fJL.
W
tJJ
Z
W
o
:i
USE CUF,l.
23. SUBSCRIBED AND SWORN TO/AFFIRMED 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.
o 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
{ } NAME (PRINT) J. 0 C. M
TIME MONTH YEAR
SEAL SIGNATURE ~ '. DATE 03/26/200
'-- .-.J MAII..!.~ ~~DII~E:'lSe AM
-v- LU IVI am ush Rd, Wappingers Falls, NY 12590 03:16pM 03
STREET CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 CIVIL
DATE AND AT THE TIME AND
PLACE INDICATED. 9 0 OTHER, SPECIFY
25 2009
by New York Domestic
MONTH
YEAR
27
2009
05
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY 7)1Jfl:J4i./.t
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY) /
o CITY OF 0 TOWN OF <<VILLAGE OM
SPECIFY w,4-pP I ~ tr1&.
\
SIGNATURE~
DOH-9B (03/2006)