005
0-
N
+
>-
z
w
UJ
w
en
Cl
-.l
::>
o
I.
UJ
Z
o
~
a:
>-
UJ
a
w
a:
w
Cl
<(
ii:
a:
<(
~
""
o
w
~
u
u:
i=
a:
w
u
w
a:
w
I
~
UJ
UJ
w
a:
Cl
Cl
<(
~
C3
W
0-
UJ
+
1i:i:z W
~~g
~~~ ~
tii~~ 0
i~~ ii:
~Z(f) _
~~t ~
!toUJ W
0>->-
w~<5 0
sm'"
z~~
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~:~c: 1368 .
~~~I~~~R 5
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Brp.tt .Justin Preuss
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Caroline Kircher
MIDDLE CURRENT SURNAME
-.J
1. A FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Prp.IISS
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 101-70-0118
12. RESIDENCE A. NY B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN Il!'l' VILLAGE
~~~CIFY Wappingers Falls
D. STREET AODRESS 2719 West Main Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? l!'l YES 0 NO
/?O /l r:J77
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 063-60-0926
2. RESIDENCE A. NY B. nlltr.hp.ss
(STATE) (COUNTY)
C. CHECK ONE 0 CITY 0 TOWN otJ VILLAGE
~~~CIFY Wappingers Falls
D. STREET ADDRESS 2719 West Main Street ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? r!f YES 0 NO
3. A. AGE 30 3B. DATE OF BIRTH n1 / 1 R / 1 r:J77
MONTH DAY YEAR
3B. DATE OF BIRTH
07
MONTH
13. A. AGE 10
4. EMPLOYMENT
A. USUAL OCCUPATION Rp.t;::Jil
B. TYPE OF INDUSTRY OR BUSINESS Wal Mart
5. PLACE OF BIRTH Newburah, New York
(CITY, STATE / 'O"OUNTRY IF NOT USA)
6. FATHER
A. NAME I~mp.~ H Prp.II~~
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Rp.vp.rly Rulson
B. COUNTRY OF BIRTH l J S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
'DIVORCE . CIVIL-ANNtJl:MENT
o n
14. EMPLOYMENT
A. USUAL OCCUPATION Restaurant Supervisor
B. TYPE OF INDUSTRY OR BUSINESS Trefz Corporation
15. PLACE OF BIRTH Yonkers New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Rir.h;::Jrd Rnhp.rt Kirr.hp.r
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Rosalie Tsitsera
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
(2) 0 DEATH
8. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
MONTH DAY
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
C. DATE LAST MARRIAGE ENDED?
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
21. SIGNATURE OF GROOM ~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
dge and belief that the information I provided is trU(1nd that I
. SIGNAT . E OF BRIDE~ M
o 0
o 0
o 0
o 0
ediment exists
W
en
z
W
o
::i
USE CU
23 ~~;fr~~~DO~N,.oO~~OJl~ ci;~Ab~~~E~ BEFORE ME DATE 01/17/?00R
This license authorizes the marriage in New York State of the above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York Stat 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)
~
{ SEAL }
'-v-I
YEAR
MONTH
YEAR
TIME
MONTH
AM
01: 19PM
03
17 2008
01
18
2008
ZIP
TATE
27. TYPE OF CEREMONY
oK RELIGIOUS
9 0 OTHER, SPECIFY
10 CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY ~.;~\,..u-./
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 'ja TOWN OF 0 VILLAGE OF
SPECIFY C\",,->- ~
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE.
DOH.9B (03/2006)