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Dutchess
COUNTY
wappinger
CITYfTO~~
DISTRICTl 68 .
NUMBER
REGISTER 1 o:l
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason Lawrence Qualter
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L D SUPPLEMENTAL FILE
FROM THE BRIDE
Nicole Marie Mills
~
1 . A. FULL NAME
11. A. FULL NAME
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Foster
c, SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl572-45-1279
D. SOCIAL SEplJfllJY NUMBER
12. RESIDENCE A. NY B. LJutchess
(STATE) ..t. (COUNTY)
C. CHECK Ot-l~ . 0 CITY i:l- TQWN 0 VILLAGE
~~~CIFY vvapplngers railS
300 Sterling Dr 12590
D. STREET ADDRESS z~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORAT8 VILLAGE? 0 YEj M ~O
13.A. AGE35 13B.DATE OF BIRTH 7 )'3 E
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Homemaker
HomemaKer
B. TYPE OF INDUATRY OR ~$INESS f
15. PLACE OF BIRTH ~ama vlara, l,;all orma
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Gregory Scott Foster
. U:SA
B. COUNTRY OF BIRTH
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)132-70-7034
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B, Dutchess
(STATE) "- (COUNTY)
C. CHECK ONF. . D. CITY 0 JOWN 0 VILLAGE
~~~CIFY vvapplngers railS
D, STREET ADDRESS 3UU :sterling ur
12090
z~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES 0 NO
AGE 34 3B. DATE OF BiRTH 02 / 15 /1976
MONTH DAY YEAR
3. A.
4. EMPLOYMENT
A. USUAL OCCUPATION Mainteilance Mechariic
5. :~::~~:I;:ugr3~~,B~I~~SyA~~ksley School LJlstnct
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Lawrence Joseph Qualter
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Nancy Nerina Leyva
B. COUNTRY OF BIRTH USA
1
8. NUMBER OF THIS MARRIAGE
17. MOTHER M A B rt I
A. MAIDEN NAME ary nn e e s
Netnerlanas
B. COUNTRY OF BIRTH 2
18. NUMBER OF THIS MARRIAGE
a:
w
CD
::IE
::>
z
Q
Z
..
tu
w
a:
Iii
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DI~ORCE CIVIL A~ULMENT
.,
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVOFfJ7 (3) ~NULMENT 2d~ 8 DEATH
c. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTH DAY YEAR MONTIIlf 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) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE ST ~'n~cf~o,'tl) Pd1JQhoreeps~~~~W ~bUr~) S~F SPOUSE
o 1 0 0
o 2ND 0 0
o 3RD 0 0
o 4TH
belief that the information I provided is true an
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV~RCE CIVIL AN5ULMENT
DE6TH
D1jTH
1ST
2ND
3RD
4TH
I duly swear/affirm, dep.Dse and say, that to the best of my
as to my right to enter into the marriage state. c/;;
21. SIGNATURE OF GROOM~
USE CURRE
23. SUBSCRIBED AND SWOR AFFIRMED 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 au
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 CI1Jo<t!wtt. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
"^-
W
CJ)
z
W
o
~
r-I'-.
{ SEAL }
~
MONTH
YEAR
TIME
MONTH
YEAR
11/04/2010
DATE
sh Rd, Wappingers Falls, NY 12590
01
03 2011
AM 11
12:30 PM
05
2010
ZIP
STATE
27. TYPE OF CEREMONY
1){ CIVIL
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
28. PLACE WHERE MARRIAGE OCCUR~
A. STATE NEW YORK B. couN~Jrllfr~')
c. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF .9 TOWN OF ~..VILLAGE OF
SPECIFY iVfif{JJJ/~ -~ MiLe;
29. OFFICIANT
NAME (PRINT)
t.i.Ilce ~
DATE DtiC. /.::; }..lJ/D
!(tj, 1J..l)qo
STATE
-,...... -..------=
NAME (PRINT)
SIGNATURE~