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COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~: 1368 .
~~~I~J~R 100
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ni~hnl~~ .Inn Fr~nle
MIDDLE CURRENT SURNAME
I
STATE FilE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Megan Elaine Augustine
MIDDLE CURRENT SURNAME
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
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N
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Ercole
(OPTIONAL' SEE REVERSE) 065 72 7650
D. SOCIAL SECURITY NUMBER --
12. RESIDENCE A. NY B. Dutchess
(ST ATE) (COUNTY)
C. CHECK ONE 0 CITY r:! TOWN 0 VILLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 2 Coach Lantern Dr ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
03 /12 /1987
MONTH DAY YEAR
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSE) 132-70-8299
D. SOCIAL SECURITY NUMBER _ -- -- ----
2. RESIDENCE A. NY B. nllt~he~~
(STATE) (COUNTY)
C. CHECK ONE 0 CITY IS1I' TOWN 0 VilLAGE
~~~CIFY East Fishkill
D. STREET ADDRESS 2 Coach Lantern Dr ZIP 12533
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES c1 NO
3. A. AGE 28 3B. DATE OF BiRTH 1? / 03 / 1981
MONTH DAY YEAR
13. A. AGE 23
13B.DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Manager Formal Wear
B. TYPE OF INDUSTRY OR BUSINESS Retail/Rental
15. PLACE OF BIRTH Buffalo. Nv
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Gary Bates Augustine
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Donna Louise Woodburn
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
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4. EMPLOYMENT
A. USUAL OCCUPATION ~ki ~hnp M~nager
B. TYPE OF INDUSTRY OR BUSINESS Retail
5. PLACE OF BIRTH (~;~~~hO~rRY IF NOT USA)
6. FATHER
A. NAME Rnhert Fr~nle
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Yvonne Dietrich
B. COUNTRY OF BIRTH Switzerland
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
(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) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
MONTH DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D 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
o 0
o 0
o 0
o 0
hat no jllg..al impediment exists
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1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the mar
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
edge and belief that the information I provided is true and that I declar
E CU
23 ~:tffT~~~DO~Nib~OR Cr~:KE~ BEFORE ME DATE 08/06/2010
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized by New York Domestic
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.
~ 24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT) Jo C. Masterson
TIME MONTH YEAR MONTH
SEAL SIGNATURE ~ DATE 08/06/201
'-- -.J MAILlf:l\lI\D~IRI'El!?e 09 33\M
-or- LU Mlcm sh Rd, Wappingers Falls, NY 12590 : 08
STREET CITYITOWN STATE ZIP PM
~~~R~~R;~~J 10~0~~~N~i~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 ~ RELIGIOUS
DATE AND AT THE TIME AND T
PLACE INDICATED. 9 0 OTHER, SPECIFY
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YEAR
07
2010
10
05 2010
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY NfJAJ ~~k.
C. LOCATION OF CEREMONY ~
(CHECK ONE AND SPECIFY)
'P CITY OF 0 TOWN OF
29. OFFICIANT
NAME (PRINT)
SPECIFY
Z
31. WITNESS TO CEI}llMONYB .
NAME (PRINT) _ I. f.J!.l. CJ... ~ _4. (ItA 1.. 0
SIGNATURE~ ~~"-\ ~ J
