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DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
SC@6Unicheel F M~~ENT SURNAME
FIRST
(THIS SPACE FOR STATE USE ONL Y)
.J
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Catherine Ann Zamoardi
MIDDLE CURRENT SURNAME
1. A. FULL NAME
11. A. FULL NAME
FIRST
a.
N
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE F II ry
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 102-66-3901
12. RESIDENCE ANY BDutchess
(STATE) (COUNTY)
c. CHECK ONE 0 CITY 0(] TOWN 0 VILLAGE
AND W .
SPECIFY appmger
D. STREET ADDREss1668 Route 9 11
ZIP 12590
o YES~ NO
;(982
YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 09!)-RR-1 ? RO
2. RESIDENCE A. N~STATE) B. ~~gJ~~~S~
C. CHECK ONE 0 CITY..lJ TOWN 0 VilLAGE
AND \N .
SPECIFY ~rrlnop.r
D. STREET ADDRESS 1668 Route 9 1 L ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES..o NO
n~ / 11 /1 9R?
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE?!) 3B. DATE OF BIRTH 11 ~2
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATloNXray Technician
B. TYPE OF INDUSTRY OR BUSINESS Medical
15. PLACE OF BIRTHQueens. Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME~aul Anthony Zampardi
'B. COUNTRY OF BIRTJ.J S A
3. A. AGE26
4. EMPLOYMENT
A. USUAL OCCUPATION Mecha"ir.~1 Fnoinp.p.r
B. TYPE OF INOUSTRY OR BUSINESS M<=lnufacturing
5. PLACE OF BIRTH POI J~hkp.p~~ip., N~
(CITY, ATE / CO TRY IF NOT SA)
6. FATHER
A. NAME Mich.ael Andrew Fllry
B. COUNTRY OF BIRTH I J S A
3B. DATE OF BIRTH
7. MOTHER
A. MAIDEN NAME [:onnip. .IA<=ln BAck
B. COUNTRY OF BIRTH I ) S A
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
o 0
17. MOTHER
A. MAIDEN NAME Ann Sweda
B. COUNTRY OF BIRTJ.J 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
DEATH
o
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
- YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
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? 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:'
w
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o 0 1~ 0 0
o 0 2ND 0 0
o 0 3RD 0 0
o 0 4TH 0 0
e t of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
22. SIGNATURE OF BRIDE~ &~ 4-- ~~
USE URR 19 USE CURRENl"flAME
23 SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE M 9/19/2008
SIGNATURE OF TOWN OR CITY CLERK~ DATE
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
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, th
as to my right to enter into the mamag
21. SIGNATURE OF GROOM~
~
{ SEAL }
'-v-'
NAME (PRINT)
YEAR
YEAR
MONTH
TIME
MONTH
08:56AM 09
PM
20
2008
11
18 2008
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
10 CIVil
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. couN~f.psf(l4gt eft
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
~ OF 0 TOWN OF 0 VilLAGE OF
SPECIFY /!/..-et.../ ? C7 o4-#l/-e
29. OFFICIANT
NAME (PRINT)
NAME (PRINT)
SIGNATURE~
DOH-98 (0312006)
NAME (PRINT)
SIGNATURE~