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1. A FULL NAME
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Jason Paul Mazzacone
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
I
COUNTY Dutchess
CITYffOWN Wappinger
~~r~~~cRT 1368
~5~'iJ~R 63
/IIevG"~ u ~ € i>
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L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Meghan Anne Smith
~
11. A. FULL NAME
MIDDLE
CURRENT SURNAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
BIRTH NAME. IF DIFFERENT
B BIRTH NAME (MAIDEN NAME), II~~NT
C SURNAME AFTER MARRIAGE acone
(OPTIONAL SEE REVERSE) O:)~ 1lJ..819~
D. SOCIAL SE~'ifNUMBER Dutchess
12. RESIDENCE A. (STATE) oJ (COUNTY)
C. CHECK Oillli..___4! CITY 0 TOWN 0 VILLAGE
AND wappinger
SPECIFY 16 BartMJra 0I1Ve
D STREET ADDRESS
12590
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)063-60-1 022
D. SOCIAL SECURITY NUMBER
2 RESIDENCE A. NY B. Dutchess
(STATE) ~ (COUNTY)
C ~~6CK ONF.... Q...CIJX TOWN 0 VILLAGE
SPECIFY tast tlSnK
D STREET ADDRESS 40 Tiger Road
3 A. AGE 28
1jl:J33
ZIP .,
YES [] NO
/1976
YEAR
ZIP
.,
E IS RES~CE WITHIN LIMITS OF CITY OR INCORPORAT'1"LLAGE? 'Ul: 0 YiiJ;lAl NO
13. A. AGE 13.B. DATE OF BIRTH ~ ~
MONTH DAY YEAR
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0
11 /10
3B. DATE OF BIRTH
MONTH
DAY
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4. EMPLOYMENT
A USUAL OCCUPATION Construction
B. TYPE OF INDUSTRY OR BUSINESS Self-employed
5. PLACE OF BIRTH Cold Spring, New York
(CITY, STATE/COUNTRY IF NOT USA)
14. EMPLOYMENT Waitress
A. USUAL OCCUPATION D.... h OJ
wC ess ner
B. TYPE OF INDUVRY icR BUSI~S orfc
15. PLACE OF BIRTH on ers, ew y
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER Mich I K
A. NAME 8e e8ne
B. COUNTRY OF BIRTH USA
17. MOTHER . R S ith
A. MAIDEN NAME LOUISa ose m
B. COUNTRY OF BIRTH U S ~
18. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV6RCE CIVIL ANWLMENT
DEtJH
6. FATHER
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A. NAME John Paul Mazzacone
B. COUNTRY OF BIRTH USA
7. MOTHER
A MAIDEN NAME Gloria Marie cunningham
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 2
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV01CE CIVIL ANrwLMENT
DEtiH
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B. HOW DID LAST MARRIAGE END? (3) 0 DIVOR'09 (3) 0 fYgULMENT 2liJj DEATH B. HOW DID LAST MARRIAGE F,ND? (3) 0 DIVORCE (3) 0 ANNULMENT (2) [J DEATH
C. DATE LAST MARRIAGE ENDED? / / C. DATE LAST MARRIAGE ENDED? / /
MONTHw'" DAY YEAR MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DA~ Y~ (CITY, STATE/COUN.TRY,!F.NOT Uiit-L.... SE~ SPOUSE (MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SElF SPOUSE
1ST 09105/~OU3 PoughkeepSie, New TUlI\ 0 0 1ST 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I, being duly sworn, depose and say, that to the best of my knowledge and belief that the information I provided is true and. t.h. a.ftl d. I.a.re that....n..o. lega~. impeJi":e exists
as to my right to enter into th ~rriagestate. 11;., '. (/ "'-/.-L/
21.SIGNATUREOFGROOM~ . ) / 22.SIGNATUREOFBRIDE~ III /;/J',~,/t..t '1
/ USE CURRENT NAME 07/11/2005
23. SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE Of TOWI\! R CITY CLERK ~ DATE
This lic,ense' authorizes lIle marriage in New York State 0 the bride and groom named above by any person authorized by New York Domestic
Rel-.tions Law ~11 to perfor-m marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
UJ _;. 0 If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ ~ 24 TOWN OR CITjQ ERKC. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
UJ { } NAME (PRINT)
o . 07/1112005 TIME MONTH YEAR MONTH
- SEAL' SIGNATURE ~ . ..., DATE
..J -- ~. MA2ff ush Rd, ppinger Falls, NY 12590 02:44~~ 07 12 2005 09 09 2005
STREE'f CITYITOWN STATE ZIP
I CERTIFY THAT I SOLEMNIZED 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
~~~sM~~~~g~B~VJ~Pi:E TIME MO. DAY YEAR 00 RELIGIOUS
DATE AND.. AT THE TIME AND
PLACE INDICATED
YEAR
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
10 CIVIL
A. STATE NEW YORK B. COUNTY
AM
PM
9 0 OTHER, SPECIFY
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 0 TOWN OF 0 VILLAGE OF
29. OFFICIANT
NAME (PRINT)
TITLE
SIGNATURE ~
MAILING ADDRESS
DATE
SPECIFY
STREET
30. WITNESS TO CEREMONY
CITYffOWN
STATE
ZIP
31 WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE ~
DOH-90 (11198)
NAME (PRINT)
SIGNATURE ~