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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason Robert Frost
MIDDLE CURRENT SURNAME
1ST
o 2ND
o 3RD
o 4TH
d belief that the Information I provided is tru
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.Dse and say, that to the best of
as to my right to enter into the marriage stat
21. SIGNATURE OF GROOM ~
USE
23. SUBSCRIBED AND SWORN TO! IRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the I"QoIrriage 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 onl for the purpose of a second or subsequent ceremony.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) John C. Maste son
{ / 1 TIME MONTH YEAR
SEAL SIGNATURE ~. DATE 06/07 20 0
'-t-I MA~I~GIOO~dr~ sh Rd, Wappingers Falls, NY 12590 01:08:~ 06 07 2010
STREET CITYITOWN STATE ZIP
~~~R~~RT~~~ 10~0~N~J~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. AY YEAR 0 0 RELIGIOUS 1 ~VIL
DATE AND AT THE TIME AND AM f7
PLACE INDICATED. \ '. \ q Co I ;).c 1 0 9 0 OTHER, SPECIFY
COUNTY Dutchess
CITYrrOWN Wappinger
~~~~f;1368
~5~1:~~R 59
1 . A. FUll NAME
FIRST
..
I'i
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEb04_90_5202
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. OranQe
(STATE) (COUNTY)
C. CHECK ONE 0 CITY~ TOWN 0 VILLAGE
~~~CIFY Highland Falls
D. STREET ADDRESS 373 Biddle Loop ZIP 10996
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES'''''o NO
3. A. AGE 25 3B. DATE OF BIRTH 05 / 09 /1985
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION US Army
B. TYPE OF INDUSTRY OR BUSINESS Military
5. PLACE OF BIRTH Wiesbaden, Hassen, Germany
(CITY. STATE! COUNTRY IF NOT USA)
6. FATHER
A. NAME Robert William Frost
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Betty Vernelle Walton
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,\IAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
100
B. HOW DID LAST MARRIAGE END? (3) ~ DIVORCE (3) 0 ANNULMENT jg) 0 DEATH
C. DATE LAST MARRIAGE ENDED? 02 / 22 / 2008
MONTtI.I DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? Ll YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CrrvICOUNTY. STATEICOUNTRY, IF NOT USA) SELF SPOUSE
02/22/2008 Comanche County, ~
DEATH
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
Lo
-.J
SUPPLEMENTAL FILE
FROM THE BRIDE
Amanda Louise Kornbau
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Frost
(OPTIONAL' SEE REVERSf{)83-70-9409
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A~Y BOrange
(STATE) ~ (COUNTY)
C. CHECK qN~ 0 CIlY TOWN 0 VilLAGE
~~CIFYHighland t-a s
D. STREETADDRES~/3 !:SIddle LOOp zlp1U~~ti
01.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES f8 NO
13. A. AGE25 3B. DATE OF BIRTH 12 ;to J-9 4
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATIONSpeech Therapist
B. TYPE OF IND~TRY OR Bl-'SINESsEducatlon
15. PLACE OF BIRTHl,;ananaalgua, Ny
(CITY. STATE! COUNTRY IF NOT USA)
16. FATHER
A. NAMERobert Richard Kornbau
. B. COUNTRY OF BIRTJJ S A
17. MOTHER . .
A. MAIDEN NAME Marltse LOUIse Weatherup
B. COUNTRY OF ~JJ S A
1
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DeORCE CIVIL A~ULMENT
D'Q'TH
(3) 0 ANNULMENT (2) 0 DEATH
/ /
.'- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
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, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
o
o
o
2' SIGNATURE OF BRIDE~
~
by New York Domestic
MONTH
YEAR
12
03 2010
26. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY l\\/TC.t.{ t S ~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF u("TOWN OF 0 VILLAGE OF
TITLE 1I1~(rl~ t9~' ( 't.r
DATE~~10
IV
ST TE
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
wM'PIN6-t!
31. WITNESS
SPECIFY
NAME (PRINT)
SIGNATURE~