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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~c; 1368 '
~~~~~~R 43
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Rene Brown
MIDDLE CURRENT SURNAME
I
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Andrea Lvnne Fretwell
MIDDLE CURRENT SURNAME
--1
1 , A, FULL NAME
11, A, FULL NAME
FIRST
FIRST
l1.
N
8, BIRTH NAME, IF DIFFERENT B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C, SURNAME AFTER MARRIAGE C, SURNAME AFTER MARRIAGE Brown
(OPTIONAL. SEE REVERSE)427 31 0056 (OPTIONAL. SEE REVERSEl055_58_0213
D, SOCIAL SECURITY NUMBER - - D, SOCIAL SECURITY NUMBER
2, RESIDENCE A AK e, Anchorage 12, RESIDENCE A New York e, Dutchess
(STATE) (COUNTY) (STATE) (COUNTY)
C, CHECK ONE ~ CITY 0 TOWN 0 VILLAGE C. CHECK ONE 0 CITY I!'l TOWN 0 VILLAGE
~~CIFY Alaska ~~~CIFY Fishkill
D. STREET ADDRESS 2309 Harbor Landing CirclezlP 99515 D. STREETADDRESS87 Townview Drive ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES '6 NO
3, A, AGE 42 3B, DATE OF BiRTH 01 /21 / 1965 13, A, AGE 45 3B, DATE OF BIRTH 01 /19 )1'962
MONTH DAY YEAR MONTH DAY YEAR
4, EMPLOYMENT
A. USUAL OCCUPATION Armed Forces
B, TYPE OF INDUSTRY OR BUSINESS U. S. A. F.
5, PLACE OF BIRTH Natchez, Mississippi
(CITY. STATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME Johnnie Brown, Jr.
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Marie Phipps
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATION Banker
B. TYPE OF INDUSTRY OR BUSINESS Chase Bank
15. PLACE OF BIRTH Greensboro, Georgia
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Earnest Fretwell
'B. COUNTRY OF BIRTHU S A
17. MOTHER
A, MAIDEN NAME Lucille Jackson
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 2
19. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
B. HOW DID lAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID lAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT ~~ DEATH
C, DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? 03 / 18 / 19
MONTH DAY YEAR MONT~ DAY, ',- YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
..
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (ClTYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY/COUNTY. STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST 0 0 1ST 03/18/1997 Bronx, New York r5
2ND 0 0 2ND
3RD 0 0 3RD
~ 0 0 ~
I duly'swear/affirm, deP.OSe and say, that to the bes1 of my knowledge and belief that the information I provided is true and t
as to my right to enter into the mamage state.
21. SIGNATURE OF GROOM~ 22. GNATURE OF BRIDE~
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
DEATH
o
23. SUBSCRIBED AND SWORN TOIAFFIRMED BEFORE ME 05/31/2007
SIGNATURE OF TOWN OR CITY CLERK ~ DATE
This license authorizes the marriage in New York State authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies wlthin New Y State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used only for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CI-ERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Jonn C. Mast
{ ~~
SEAL SIGNATURE ~
'-v-I MA~tf~cf~b 07 30 2007
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY ~iJK.:tI(:;-s.>
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
ci CITY OF 0 TOWN OF 0 VILLAGE OF
SPECIFY "& rJ c~ IJ I tJ f.
...
ZIP
31. WITNESS TO reafMONY",tl~,. .
NAME (PRINT) Cd.. W o..r;),ON
SIGNATURE~ ~ m .' .