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COUNTY Dutchess
CITYrrOWN Wappinger
~~~~~c: 1368 .
~5~1~~~R 87
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason Joseph Mazzotti
MIDDLE CURRENT SURNAME
,;,111/1.11;:: r"1L.C I..umlc:n~n
(THIS SPACE FOR STA TE USE ONL Y)
SUPPLEMENTAL FILE
FROM THE SRI DE
Adele Marie Henning
MIDDLE CURRENT SURNAME
~
Lo
1 . A. FUUL NAME
1 1. A. FULL NAME
FIRST
FIRST
B. BIRTH NAME, IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Mazzotti
(OPTIONAL. SEE REVERSE) 064-68-8822
D. SOCIAL SECURITY NUMBER
12. RESIDENCE A, New York B. Dutchess
(ST ATE).J (COUNTY)
C. CHECK ONE 0 CITY LJ TOWN 0 VILLAGE
D. :~:~; AD~:~~~n~~rothY Heights ZIP 1 ~t>~U
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
06 /11 )1'977
DAY YEAR
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 063-66-8620
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY l!1 TOWN 0 VILLAGE
~~~CIFY Wappinger
D STREET ADDRESS 14 Dorothy Heights ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES ~ NO
03 / 03 / 1974
YEAR
13. A. AGE 29
3B. DATE OF BIRTH
3. A. AGE 32
3B. DATE OF BIRTH
MONTH
DAY
MONTH
14. EMPLOYMENT
A. USUAL OCCUPATION Registered Nurse
B. TYPE OF INDUSTRY OR BUSINESS Westchester Medical
15. PLACE OF BIRTH New Rochelle, New York
(CITY. STATE / COUNTRY IF NOT USA)
4. EMPLOYMENT
A. USUAL OCCUPATION Engineer
B. TYPE OF INDUSTRY OR BUSINESS IBM Corp.
5. PLACE OF BIRTH Plattsburgh, New York
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Steven Henning
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Linda Shallash
B. COUNTRY OF BIRTH U S ~
1B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
D~H
6. FATHER
A. NAME Joseph Mazzotti
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Mary Anne Rosselli
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVOBCE CIVIL ANN~LMENT
DEAOH
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
B. HOW DID LAST MARRIAGE END?
(3) 0 DIVORCE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
. . - YEAR
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
(MONlTH, 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
o 0
o 0
o 0
o 0
no legal imQediment exists
1ST
2ND
3RD
4TH
I duly swear/affirm, depose and say, that to the best of
as to my right to enter into t e marnage state,
21. SIGNATURE OF GROOM
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
owledge and belief that the information I provided is true an
w
en
z
w
(J
::i
23. SUBSCRIBED AND SWORN T I FIRMED BEFO
SIGNATURE OF TOWN OR CI CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 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 CITYICl,~RK C M t 25 A SOLEMNIZATION PERIOD BEGINS
",onn . as erson . .
NAME (PRINT)
MONTH
YEAR
by New York Domestic
~
{ SEAL }
'-v-I
TIME
MONTH
YEAR
07/05/200
DATE
appinger Falls, NY 12590
09
03 2006
AM
06:28pM
07
06
2006
SIGNATURE ~
MAILm tbW
ZIP
STATE
27. TY,?"OF CEREMONY
o ~ELlGIOUS
9 0 OTHER, SPECIFY
CITYiTOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUN,J)hrcH1;sS
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF ~LAGE OF
SPECIFYvVltPfrtY fr;:R~ ~
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
()~
:2.f
?
1<; C. ! R..iff/
7/).{ It) {,
TITLE
I vl'r cJ
NAME (PRINT)
SIGNATURE~
NAME (PRINT)
SIGNATURE~
DOH-98 (03/2006)