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COUNTYDutchess
CITYfTOWN Wappinger
~~~~~c~1368 '
~5~:J~R19
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Ga~ Bruce Mazzetti
IDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
SUPPLEMENTAL FILE
FROM THE BRIDE
Patricia Ann Balluff
~
Lo
1 , A. FULL NAME
11. A. FULL NAME
CURRENT SURNAME
FIRST
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAMEj..JF DIFFEREi reer
C. SURNAME AFTER MARRIAGrf reer -m azzettl
(OPTIONAL - SEE REVERS{)95-42-2338
D. SOCIAL SECURITY NUMBER II
12. RESIDENCE ~Y It': utcness
(STATE) ..I. (COUNTY)
C. CHECK P~l .0 CITY 0 TOWN 0 VilLAGE
~~~CIp,Y ~ applnger
STREET ADDREsfL Balfour Dr
.,
Y~~ONO
YEAR
"-
F:l
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSIih50_52_5644
D. SOCIAL SECURITY NUMBER U
2. RESIDENCEA.NY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CIn""tJ TOWN 0 VILLAGE
~~~CIFY Wappinger
D. STREET ADDRESS22 Balfour Dr ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEt 0 NO
05 /02 /1954
MONTH DAY YEAR
12590
ZIP
D.
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPOA.()~ VIULAGE1...d 0
13. A. AG~9 3B. DATE OF BIRTH ~
MONTH DAY
14. EMPLOYMENT . .
A. USUAL OCCUPATIO~D Billing
Medical
B. TYPE OF IND~TRY ~~USINESS
15. PLACE OF BIRnLoug eepSle, NY
(CITY, STATE I COUNTRY IF NOT USA)
16. FATHER
A. NAM~dmund J. Freer
. B. COUNTRY OF BIRT~ :::i A
17. MOTHER .
A. MAIDEN NAM~gnes Smsavage
B, COUNTRY OF BIRTtV :::i ~
3. A. AGE55
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Enviromental Analyst
B. TYPE OF INDUSTRY OR BUSINESS Columbia Analytical
5. PLACE OF BIRTHPoughkeepsie, Ny
(CITY, STATE I COUNTRY IF NOT USA)
I-
~
6. FATHER
A. NAME Frank Mazzetti
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Joyce Minard
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MAR81AGE 2
18. NUMBER OF THIS MARRIAGE
a:'
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9. ~~~~~~~R~FR~KEWr8us MARRIAGES WHICH ENDED BY 19. ~~~~~~~R~FR~K'E<t'r8us MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT DEATH D11VORCE CIVIL AjllNULMENT
100 u
~ ~
B. HOW DID LAST MARRIAGE END? (3) U DIVORCE (3) 0 ANNULMENT E) 0 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 D1VO~8 (3) ~ fNULMENT 19~fl DEATH
C. DATE LAST MARRIAGE ENDED? 02 / 10 / 1 ~95 C. DATE LAST MARRIAGE ENDED? / /
MON1'!J,o DAY YEAR MONTolf DAY'/ YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? ~ YES 0 NO D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
to
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLL-oWING INFORMATION 20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED . . . . . AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITYICOUNTY, STATElCOUNTRY. IF NOT USA) SELF SPOUSE j.MONTH..I D~Y9~)P lPITY/COUNJ:(, STATElPOUNll1Y. IF NOT USA) SELF SP~SE
1ST 02/10/1995 Wake County, Nc ~ 0 1ST u8/1.11 'd{ umam l,oumy, I'IIY 0 0
2ND 0 0 2ND 0 0
3RD 0 0 3RD 0 0
4TH 0 0 4TH 0 0
I duly swear/affirm, dep.ose and say, that to the best of my knowledge and belief that the information I provided is true al impediment exists
as to my right to enter into the marnage state.
21. SIGNATURE OF GROOM~ . ~ SIGNATURE OF BRIDE~
USE CUR
23. SUBSCRIBED AND SWORN TO/AFFIRMED BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the marriage in New York State of the bride and groom named above by any person authorized
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
{ } NAME (PRINT) John C. Masterson
1 YEAR MONTH DAY YEAR
SEAL SIGNATURE ~ DATE 03/19/20 0
'-V-I MA~5GIOOW Is, NY 12590
STREET STATE
I CERTIFY THAT I SOLEMNIZED 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE 0 0 RELIGIOUS
DATE AND AT THE TIME AND
PLACE INDICAT 9 0 OTHER, SPECIFY
DO"'TH
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
05
18 2010
ZIP
1~
28. PLACE WHERE MARRIAGE OCCU~ _
A. STATE NEW YORK B. COUNT'ffiI.lIC.;/t.d
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY h s:h }:::./I,[., N .'f.
NAME (PRINT)
SIGNATURE~
NAME (PRINT)
SIGNATURE~