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COUNTY Dutchess
wappinger
CITYfTOViN
DISTRICTl 35l:S .
NUMBER
REGISTER 1 54
NUMBER
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Benjamin Christian Asplund
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Kimberly Alyssa EI-Kadi
MIDDLE CURRENT SURNAME
.J
1 . A. FULL NAME
11. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Asplund
(OPTIONAL - SEE REVERSEl128-68-6966
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. NY BDutchess
(ST A TEl.L (COUNTY)
C. CHECK O~i . 0 CITY 0 TOWN 0 VILLAGE
~~~CIFY wappinger
D. STREET ADDRESs4A t.;nelsea Kloge ur
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSEl489_98_0234
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. NY B. Dutchess
(STATE).L. (COUNTY)
C. CHECK ONE 0 CITY ~u TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS 4A Chelsea Ridge Ur
llo9u
ZIP '"
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEj ..Q.4NO
13. A. AGE26 13B.DATE OF BIRTH 04 ~5 ~
MONTH DAY YEAR
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Administrative
B. TYPE OF INDUATRf OR BU~ESS uental
15. PLACE OF BIRTH~U fern, ew York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME M. Hisnam M. EI-Kadi
'B. COUNTRY OF BIRTHLebanon
17. MOTHER . H' I
A. MAIDEN NAME Jackl Ravena II
B. COUNTRY OF BIRTHU S ~
1B. NUMBER OF THIS MARRIAGE
4. EMPLOYMENT
A. USUAL OCCUPATION Flight Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Manne Corps
5 PLACE OF BIRTH Independence, Mlssoun
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Kirby K. AS~lund
B. COUNTRY OF BIRTH U A
7. MOTHER
A. MAIDEN NAME Tamara Ann Martin
B. COUNTRY OF BIRTH USA
B. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVBRCE CIVIL ANBULMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D~ORCE CIVIL A~ULMENT
D'tl TH
DE6TH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
(3) 0 ANNULMENT (2) D DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) D DIVORCE
C. DATE LAST MARRIAGE ENDED?
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? DYES D NO
"
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) ICITY/COUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
C. DATE LAST MARRIAGE ENDED?
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) (CITY/COUNTY, STATE/COUNTRY. IF NOT USA) SELF SPOUSE
a:
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1Il
D
D
D
1ST
2ND
3RD
4TH
I duly swear/affirm. depose and sa
as to my right to enter into the
21. SIGNATURE OF GROOM"
D D 1ST
D D 2ND
D D 3RD
D D 4TH
knowledge and belief that the information I provided is true an
USE CURRENT NAME 11/08/201 0
DATE
USE CUR
23. SUBSCRIBED AND SWORN TO/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 authorized
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
D If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CIl)' C<LER~ M t 25 A SOLEMNIZATION PERIOD BEGINS
JOnn v. as erson . .
NAME (PRINT)
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
"-.t-I
MONTH
DAY
YEAR
YEAR
11/08/2010
DATE
d, Wappingers Falls, NY 12590
05
07 2011
ZIP
STATE
27. TYPE OF CEREMONY
o D RELIGIOUS
9 D OTHER, SPECIFY
2B. PLACE WHERE MARRIAGE OCCURRE9j ,
A. STATE NEW YORK B. COUNTY,Ur.ttCfl8:.
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
D CITY OF 0 TOWN OF );i.VILLAGE OF
SPECIFY !I/jfIfJitfr:nC~S mj.-.).S
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED'~
29. OFFICIANT . ,,0.....
NAME (PRINT) [;J::::-
1~CIVIL
NAME (PRINT)
SIGNATURE~
DOH-9B (09/2009)
NAME (PRINT)
SIGNATURE~