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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Michael John Amato
MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITYrrOWN Wappinger
~~~:~:1368 .
~5~:J~R 28
1. A. FULL NAME
FIRST
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)087 68 4257
D. SOCIAL SECURITY NUMBER --
2. RESIDENCE A. NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITYo(] TOWN 0 VILLAGE
~~~CIFY Wappinoer
D. STREET ADDRESS 2 Maurice Dr. ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES tJ NO
07 /21 /1979
MONTH DAY YEAR
3. A. AGE 29
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Planner
B. TYPE OF INDUSTRY OR BUSINESS Utility
5. PLACE OF BIRTH New Rochelle
(CITY, STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME John Thomas Amato
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Judith Marouerite Johnson
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
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, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
(TH/S SPACE FOR aTA Tr USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Jessica Anne Mazzola
MIDDLE CURRENT SURNAME
~
11. A. FUll NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Amato
(OPTIONAL. SEE REVERSE)158_68_5395
D. SOCIAL SECURITY NUMBER
12. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY '6 TOWN 0 VILLAGE
~~~CIFY Wa~inger
D. STREET ADORES Maurice Dr.
ZIP 12590
o YES '6 NO
)'979
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE30 3B. DATE OF BIRTH 03 ~4
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Receptionist
B. TYPE OF INDUSTRY OR BUSINESS Veterinarian
15. PLACE OF BIRTH Westwood, NJ
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Craio Anthony Mazzola
'B. COUNT~Y OF BIRTHU S A
17. MOTHER
A. MAIDEN NAME Mary Antoinette Catrini
B. COUNTRY OF BIRTHU S A
18. NUMBER OF THIS MARRIAGE 1
'19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
(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
to
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 .
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th t to
as to my right to enter into the ma~! S
21. SIGNATURE OF GROOM.
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
my knowledge and belief that the information I provided is true
USE CURR
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 al1d 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.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT) J
~
{ SEAL }
'-v-I
SIGNATURE ~
MAILING ADDR
20 Mid Ie
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
DATE
by . New york Domestic
TIME
MONTH
YEAR
AM
01 :36PM 05
01
2009
06
29 2009
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY !JjS5.-1-U
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~GE OF
SPECIFY (j) 1U./~7rJ;J jJ.fI2,t..