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COUNTY Dutchess
CITYiTOWN Wappinger
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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason Robert Frost
MIDDLE CURRENT SURNAME
\ "..~.....' ,......-. -" -
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Amanda Louise Kornbau
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
"-
N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Kornbau
(OPTIONAL, SEE REVERSEl083_70_9409
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A.NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY tJ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS9 B Canterbury Lane
6. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 0 0
D SOCIAL SECURITY NUMBER 004-9 -52 2
2 RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C CHECK ONE 0 CITY 0{] TOWN 0 VILLAGE
AND W .
SPECIFY apomger
D. STREET ADDRESS 9 B Canterbury Lane ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
05 /09 /1985
MONTH DAY YEAR
ZIP 12590
DYES '6 NO
)1'984
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 24 3B. DATE OF BIRTH 12 /1 0
3. A. AGE ?~
3B. DATE OF BIRTH
MONTH
DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Speech Therapist
B. TYPE OF INDUSTRY OR BUSINESS Education
15. PLACE OF BIRTH Canandaigua, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Robert Richard Kornbau
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A MAIDEN NAME Marlise Louise Weatherup
B. COUNTRY OF BIRTH USA
1B. NUMBER OF THIS MARRIAGE 1
4. EMPLOYMENT
A USUAL OCCUPATION US Army
B TYPE OF INDUSTRY OR BUSINESS Militarv
5. PLACE OF BIRTH Wiesbaden. Hassen. Germanv
(CITY, STATE / COUNTRY IF NOT USA)
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S;
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6. FATHER
A. NAME Robert William Frost
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Betty Verne lie Walton
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 2
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID LAST MARRIAGE END? (3) I!'I'DIVORCE (3) 0 ANNULMENT
C. DATE LAST MARRIAGE ENDED? 02/ 22 /
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? (<f'YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) ICITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1ST 02/22/2008 Comanche County 0 1'1 1ST
2ND 0 0 2ND
~ 0 0 ~
4TH 0 0 4TH
I duly swe!lr/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is tru
as to my right to enter mto the marriage s
o 0
o 0
o 0
o 0
and that I declare th t no legal impediment exists
(2) 0 DEATH
2008
YEAR
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
21. SIGNATURE OF GROOM~
DATE 03/02/2009
by New York Domestic
SEC
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the mar'riage 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
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{ SEAL}
'-.t-'
YEAR
YEAR
MONTH
NAME (PRINT)
TIME
MONTH
DATE 03/02/200
s NY 12590
STATE ZIP
27. TYPE OF CEREMONY
1~
AM
03:05PM
03
03
2009
08
29 2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNrd2C4 t'l.Jf~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
'DCIFY W ~~ ,tJ,1ILC ~
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.