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COUNTY rlllkhp.ss
CITYrrOWN Wappinger
~~~:kc; 1 ::l6R .
~~~';;~R 96
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Tr~~ Justin LEC~~&SURNAME
FIRST
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
St::ltSif6~ Ann nOi~~~jNT SURNAME
~
1 . A. FULL NAME
11. A. FULL NAME
FIRST
0-
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D SOCIAL SECURITY NUMBER fi 1 q-1 ::l-fl::lflO
2. RESIDENCE A. N}fTATE) B ~~J#)
C. CHECK ONE 1tI CITY 0 TOWN 0 VILLAGE
~~~CIFY Hp.nrlp.rsnn
D. STREET ADDRESS 1636 Box Step Drive ZIP 89014
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES fi!'l NO
3. A. AGE 28 3B. DATE OF BIRTH 1 ~ / 19 / ~ 978
-- MONTHI DAY yhR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 053 70 0966
D. SOCIAL SECURITY NUMBER ___ - __ - ____
12. RESIDENCE A. N\I B r.1::lrk
(STATE) (COUNTY)
C. CHECK ONE !li!J CITY 0 TOWN 0 VILLAGE
~~~CIFY Henderson
o STREET ADDRESS 1636 Box Step Drive
ZIP 89014
DYES I!'I NO
A9RO
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE ?fl 3B. DATE OF BIRTH 09 /04
MONTH ~A Y
4. EMPLOYMENT
A. USUAL OCCUPATION Sy!::tAm Arlmini!::tr::ltnr
B. TYPE OF INDUSTRY OR BUSINESS Timet
5. PLACE OF BIRTH Pocatello, Idaho
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME RRrtnn PRrl I Awi!::
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Cay Venese Frahm
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 System Administrator
B. TYPE OF INDUSTRY OR BUSINESS I. B. M.
15. PLACE OF BIRTH
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME .Jel7'Y Oginski, Jr
. B. COUNTRY OF BIRTH Germany
17. MOTHER
A. MAIDEN NAME Jodie Ann Peters
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS ,,!ARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(2) 0 DEATH
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
C. DATE LAST MARRIAGE ENDED?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
B. HOW DID.LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES D NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUEO AGAINST WHOM
(MONTH, DAY, YEAR) (CITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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
o 0 1ST 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
owledge and belief that the Information I provided IS true and that I declare that no legal impediment eXists
22 NATURE 0 BRIDE ~ G\ f"'L . r
~ ~NAME
DATE 08/16/2007
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23. SUBSCRIBED AND SWORN TOIAFFIRME BEF RE
SIGNATURE OF TOWN OR CITY CLERK"
This license authorizes the marriage in New York State of the brid
Relations Law ~11 to perform marriage ceremonies within New York State. TH LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the purpose Df a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Joh C. Master
TIME MONTH DAY YEAR
SEAL SIGNATURE"
'-v-I MAI~~~~al~b 01:14~~ 08
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
15 2007
by New York Domestic
MONTH
YEAR
10
17
2007
l~CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COU~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF lS. TOWN OF 0 VILLAGE OF
SPECIFY~ptrrG ~ <:.
NAME (PRINT)
NAME (PRINT)
SIGNATURE"