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COUNTY Dutchess
CITYITOWN Wappinger
~~~~ 1368 '
~5~:J~R 11 0
~
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Joseoh Camobell Ambrose
MIDDLE CURRENT SURNAME
FIRST
I
STATE FILE NUM"~"
(THIS SPACE FOR STA TE USE ONL Y)
Lo
SUPPLEMENTAL FILE
FROM THE BRIDE
Christine Chin-An Tsai
MIDDLE CURRENT SURNAME
1, A. FULL NAME
11. A. FULL NAME
FIRST
B. BIRTH NAME. IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 372-92-4444
D. SOCIAL SECURITY NUMBER
2. RESIDENCE A. MA B. Suffolk
(STA~ . (COUNTY)
C. CHECK ONE I!J CITY 0 TOWN 0 VILLAGE
~~~CIFY Boston
D. STREET ADDRESS 200 Saint Botolph St. Unit ~P 02115
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? dYES 0 NO
3. A. AGE 25 3B. DATE OF BiRTH 04 / 04 / 1981
MONTH DAY YEAR
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Ambrose
(OPTIONAL - SEE REVERSE) 053-68-6636
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A. MA B. Suffolk
(STA'!5I (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~CIFY Boston
D. STREET ADDRESS 200 St. Botolph St. Unit 3 ZIP 0211b
E. IS RESIDENCE WITHIN UMITS OF CITY OR INCORPORATED VILLAGE? 6 YES 0 NO
13. A. AGE 23 3B. DATE OF BIRTH 11 /29 /1982
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Analyst
B. TYPE OF INDUSTRY OR BUSINESS Potomac Realty Cap.
5. PLACE OF BIRTH Blair, Pennsylvania
(CITY, STATE I COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Student
B. TYPE OF INDUs.I.RY OR,BI,ISINESS Boston University
15. PLACE OF BIRTH I-"OugnKeepsle, New YorK
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAME Pei Yann Tsai
. B. COUNTRY OF BIRTH Chma
17. MOTHER
A. MAIDEN NAME Jane Pien
B. COUNTRY OF BIRTH I alwan
1
6. FATHER
A. NAME James J. Ambrose II
B. COUNTRY OF BIRTH USA
7. MOTHER
Joanne Treat Campbell
USA
A. MAIDEN NAME
B. COUNTRY OF BIRTH
1
B. NUMBER OF THIS MARRIAGE
1B. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV05CE CIVIL ANNtlLMENT
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
D1V8RCE CIVIL AN~LMENT
D~H
D~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (2) 0 DEA'JH
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) (CITYICOUNTY, STATEICOUNTRY, IF NOT USA) SELF SPOUSE
(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
~
20. IF PREVIOUSLY DIVORCED OR ANNULlED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
!l!
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Z
Q
~
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1ST 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
~ 0 0 ~ 0 0
I duly swear/affirm, depose and say, that to the best of my knowledge and belief that the information I provided is true and that I declare that no legal impediment exists
as to my right to enter into the marnage state. "
21. SIGNATURE OF GROOM~ E OF BRIDE~ ~ ~
23. SUBSCRIBED AND SWORN T FIRMED BEFORE tJ:E USE CURRENT NAME 07/28/2006
SIGNATURE OF TOWN OR CITY CLERK,- DATE
This license authorizes the marriage in New York State of th bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to perform marriage ceremonies within New York S te. THIS LICENSE VALID IN NEW YORK STATE ONLY.
o If checked, this license is to be used 0 Iy for the urpose of a second or subsequent ceremony.
~ 24. TOWN OR CIT'j8ft'?f C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
{ } NAME (PRINT)
YEAR MONTH
SEAL SIGNATURE"
MAIL2e ~~fe 2006 09 26 2006
'-v-I
STREET CITYfTOW
~~~R~~RU'~J lo~O~~NI!:~ 26. SOLEMNIZATION OCCURRED
SONS NAMED ABOVE ON THE TIME MO Y YEAR
DATE AND AT THE TIME AND AM
PLACE INDICATED. l;! (2.1 0 <0 9 0 OTHER, SPECIFY
29.0FFICIANT .ifTf1E-s. w .~../2~_('/.v 3/U) .M1J1Jl bTf~
NAME (PRINT) r TITLE I"
I. ~ -:l I . 7 J "Z" /u (.
VV'- ~ DATE
D(;F"jjfl.. ~, KS/ ()
STREET CITYITOWN STATE ZIP
30. WITNESS TO CEREMONY {I 31. WITNESS TO P.5BEMONY
NAME (PRINT) " J eo_I"} ni tff' (. TS~ NAME (PRINT) \:am.e
YEAR
STATE
27. TYPE OF CEREMONY
o ~ELIGIOUS
ZIP
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY f)U/CffCSS
10 CIVIL
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF XTOWN OF 0 VILLAGE OF
t'OJ ~ rU./;...fs If--
SPECIFY "
~
SIGNATURE'-
DOH-9B (0312006)
SIGNATURE'-