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COUNTY Dutchess
CITYITOWN Wappinger
~~~:~~ 1368 '
~~~I:;~R 139
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
K~le SteRhen Carlson
MIDDLE CURRENT SURNAME
I"
STATE ALE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kristen Victoria Gruendle
MIDDLE CURRENT SURNAME
.J
1. A, FULL NAME
11. A, FULL NAME
FIRST
FIRST
0-
N
B,' BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL-SEE REVERSE) 057688131
D. SOCIAL SECURITY NUMBER --
2 RESIDENCE A, North Carolina B, Wake
(STATE) (COUNTY)
C. CHECK ONE 0 CITY cY' TOWN 0 VILLAGE
~~~CIFY Cary
0, STREET ADDRESS 108 Lasky Court ZIP 27511
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES rY NO
3, A. AGE 27 3B, DATE OF BIRTH 10 / 31 / 197
MONTH DAY YEAR
B, BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Carlson
(OPTIONAL - SEE REVERSE) 126-66-5686
0, SOCIAL SECURITY NUMBER
12, RESIDENCE A, North Carolina B Wake
(STATE) (COUNTY)
C, CHECK ONE 0 CITY 01 TOWN 0 VILLAGE
~~~CIFY Cary
0, STREET ADDRESS 108 Lasky Court ZIP 27511
E, IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO
13. A. AGE 26 3B. DATE OF BIRTH 04 / 17 /1980
MONTH DAY YEAR
4. EMPLOYMENT
14, EMPLOYMENT
A. USUAL OCCUPATION Photographer
B. TYPE OF INDUSTRY OR BUSINESS Lifetouch
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
A. USUAL OCCUPATION Automotive Detailer
B. TYPE OF INDUSTRY OR BUSINESS Triangle Rent A Car
5. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE I COUNTRY IF NOT USA)
16, FATHER
A. NAME Jerry D. Gruendle
'B. COUNTRY OF BIRTH USA
17, MOTHER
A. MAIDEN NAME Carol Lynn Gearhart
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
DEAOH
6, FATHER
A. NAME Keith Harry Carlson
B. COUNTRY OF BIRTH USA
7. MOTHER
A, MAIDEN NAME Carol Ann Whitbeck
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
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT (2) 0 DEATH
/ /
, - YEAR
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) (CITYICOUNTY, STATElCOUNTRY, 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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that t
as to my right to enter into the I
21, SIGNATURE OF GROOM~
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
the best of my knowledge and belief that the information I provided is true and that I deel
te, .....
22, SIGNATURE OF BRIDE ~
,
o 0
o 0
o 0
o 0
that no legal impedime t exists
USE URRENT AME
23, SUBSCRIBED AND SWORN TOIAFF ED 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,
r-I'-.. 24. TOWN OR CITY pL~RK C M t 25. A, SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) JOnn . as erson
{SEAL} SIGNATURE'-
MAIL~n~ffi
'-v-'
STREET CITYITOWN
~~~R~~Rir~J IO~O~~N~Z:~ 26, SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME M , AY YEAR
DATE AND AT THE TIME AND AM
PLACE INDICATED, \ l ~to PM
by New York Domestic
YEAR
MONTH
YEAR
DATE 08/31/200
appinger Falls, NY 12590
10
30 2006
2006
ZIP
STATE
27, TYPE OF CEREMONY
o tlO RELIGIOUS
9 0 OTHER, SPECIFY
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A STATE NEW YORK B, COUNTY Oi tt-<Yle'S 5
C, LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF Ilff VILLAGE OF
29 OFFICIANT () J::. ~ . + 1V1' . 1..- (
NAME (PRINT) t\P V JaM / u. f"\ a" \ Z TITLE ---!..J I 11\ 5, C
SIGNATURE'- 'ilnt",~Q \.fB. l17<:;t tr DATE ql '1\ D~
MAILING ADDRES~ -'-"-t -=-!-el.J
~RE~e~\(?( Aue.nl~YIT~~t.L-\-h J WGppln3prS~ATfu.lI)) N Y 1;)'6~9
30, WITNESS TO CEREMONY 31, WITNESS TO CEREMONY
NAME (PRINT) l'l' () \ V To
fa. \ \ S
SPECIFY\AJc.rpi nj ers
NAME (PRINT)
SIGNATURE'-
DOH-98 (0312006)