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170 + !z ~ w :> '" c( W III C 9 u:: => 0 U. J: '" c( ~ ~ a w a: w ~ it a: ~ ... 0 ~ (,.l iL >= a: w (,.l w a: w ~ '" '" w a: c c < ~ u W 0.. '" w -UJ Z -W (,) :l + ~~~ W ~~~ ~ tii~~ (j =>(,.l~W ::iCJ u:: !z?; - ~~~ t: fECi", W ~~~ (,) t!!ffitn ~3?; COUNTY Dutchess CITYrrOWN Wappinger ~~~:~c: 1368 . ~5~I:J~R 170 STATE OF NEW YORK DEPARTMENT OF HEALTH AFFIDAVIT, LICENSE and CERTIFICATE OF MARRIAGE FROM THE GROOM Jason R. Minard MIDDLE CURRENT SURNAME FIRST I" STATE FILE NUMBER (THIS SPACE FOR STATE USE ONLY) I Lo 1. A. FULL NAME 1 1. A. FULL NAME SUPPLEMENTAL FILE FROM THE BRIDE Danielle Mazzacone MIDDLE CURRENT SURNAME ~ FIRST 0.. N B. BIRTH NAME, IF DIFFERENT C. SURNAME AFTER MARRIAGE (OPTIONAL - SEE REVERSE) 100-66-7555 D. SOCIAL SECURITY NUMBER 2. RESIDENCEA. New York B. Dutchess (STATE) (COUNlY) C. CHECK ONE 0 CITY rY TOWN 0 VILLAGE ~~~CIFY East Fishkill D. STREET ADDRESS 80 Hosner Mountain Road ZIP E. IS RESIDENCE WITHIN UMITS OF CIlY OR INCORPORATED VILLAGE? 0 3. A. AGE ?4 3B. DATE OF BiRTH 4. EMPLOYMENT A, USUAL OCCUPATION Mechanic B. TYPE OF INDUSTRY OR BUSINESS D C H Heart Acura 5. PLACE OF BIRTH Town Of Cortlandt. New York (CITY, STATE I COUNTRY IF NOT USA) B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT C. SURNAME AFTER MARRIAGE Mazzacone - Minard (OPTIONAL - SEE REVERSE) 077 64 5802 D. SOCIAL SECURITY NUMBER -- 12. RESIDENCE A. New York e, Dutchess (STATE) (COUNlY) C. CHECK ONE 0 CITY 0 TOWN lY' VILLAGE ~~CIFY Waooinaers Falls D. STREET ADDRESS 16 West Academy Street ZIP 12590 E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ~ YES 0 NO 13. A. AGE 26 3B. DATE OF BIRTH 06 / 07 /1980 MONTH DAY YEAR 12533 YES r:I NO 14. EMPLOYMENT A. USUAL OCCUPATION Unemoloyed B. TYPE OF INDUSTRY OR BUSINESS 15. PLACE OF BIRTH PouQhkeepsie, New York (CITY, STATE I COUNTRY IF NOT USA) 6. FATHER 16. FATHER A. NAME Daniel Mazzacone 'B. COUNTRY OF BIRTH USA 17. MOTHER A. MAIDEN NAME Linda Marie Sid ate B. COUNTRY OF BIRTH USA 18. NUMBER OF THIS MARRIAGE 1 19. PREVIOUS MARRIAGES A. NUMBER OF PREvrOUS MARRIAGES WHICH ENDED BY DIVORCE CIVIL ANNULMENT o 0 DEATH o A. NAME Donald Richard Minard B. COUNTRY OF BIRTH USA 7. MOTHER A. MAIDEN NAME Nancy Elizabeth Cole 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 (3) 0 ANNULMENIT (2) 0 DEATH 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) (CITYICOUNlY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE 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) (CITYICOUNlY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (3) DANNULMENIT (2) 0 DEATH / / . ',- YEAR o 0 1ST o 0 2ND o 0 3RD o 0 4TH of my knowle,!:!ge and belief that the information I provided is true o o o USE C RE NAM 23. SUBSCRIBED AND SWO O/AFFIRMED BEFORE ME SIGNATURE OF TOWN OR CITY CLERK ~ DATE This license authorizes the marriage in New' York State of authorized by New York Domestic Relations Law ~11 to perform marriage ceremonies within New Yo te. THIS LICENSE VALID IN NEW YORK STATE ONLY. o If checked, this license is tei 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. Mas erson {TIME MONTH YEAR MONTH SEAL SIGNATURE ~ DATE 1 0/25/200 '-- -..J MAIL~(:I.APW!I'l.~~ AM 06 12 24 2006 -v- LU MICOl appinger Falls, NY 12590 03:0&>M 10 26 20 STREET ClTYrrowN STATE ZIP I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY ~ THE MARRIAGE OF THE PER- SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 CIVIL DATE AND AT THE TIME AND PLACE INDICATED. 9 0 OTHER, SPECIFY YEAR 26. PLACE WHERE MARRIAGE OCCURRED A. STATE NEW YORK B. cou~U1'GHst& C. LOCATION OF CEREMONY (CHECK ONE AND SPECIFY) ./ o CITY 0/ 0 TOWN OF ~ILLAGE OF SPECI;;-'U)~Pi7rk'irl-,. ~ NAME (PRINT) SIGNATURE~ ' OOH-98 (0312006) SIGNATURE~