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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Fra'1~D~aul PagaPu~RE~~RNAME
COUNTY Dutchess
CITYfTOWN Wappinqer
~~~:~c; 1368 .
~~~I~~~R 89
1 . A FULL NAME
FIRST
Q.
N
B. BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 057-72-6141
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
~~~CIFY Wappinqer
D. STREET ADDRESS 306 Chelsea Cay ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES r:f NO
3. A. AGE 25 3B. DATE OF BIRTH 09 / 23 / 1980
MONTH DAY YEAR
4. EMPLOYMENT
A. USUAL OCCUPATION Service Technician
B. TYPE OF INDUSTRY OR BUSINESS Daley Oil
5. PLACE OF BIRTH Newburgh, New York
(CITY. STATE / COUNTRY IF NOT USA)
6. FATHER
A. NAME Frank Paul Paqano
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Debra Ann Denton
B. COUNTRY OF BIRTH USA
1
B. NUMBER OF THIS MARRIAGE
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
(31 0 ANNULMENT
/ /
(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) (CITYICOUNTY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Melissa Anne Konunchuk
MIDDLE CURRENT SURNAME
11. A. FULL NAME
FIRST
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAGE Pagano
(OPTIONAL - SEE REVERSE) 130-84-4848
D. SOCIAL SECURITY NUMBER
12 RESIDENCEA. New York B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY rI TOWN 0 VILLAGE
~~~CIFY Wappinqer
D STREET ADDRESS 306 Chelsea Cay ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d' NO
13. A. AGE 25 3B. DATE OF BIRTH 03 /12 /1981
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Analyst
B. TYPE OF INDUSTRY OR BUSINESS Pepsi Corp.
15. PLACE OF BIRTH Brooklyn, New York
(CITY. STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAME Peter James Konunchuk
'B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Elaine Marie Dawson
B. COUNTRY OF BIRTH USA
1
1B. NUMBER OF THIS MARRIAGE
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIV8RCE CIVIL AN~LMENT
DE'8H
B. HOW DID LAST MARRIAGE END?
(31 0 DIVORCE
(31 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
(MONTH, DAY, YEAR) (CITY/COUNTY. STATE/COUNTRY, IF NOT USA) SELF SPOUSE
~~22~SZ~:E~O:7:!'-
o
o
o
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
my knowledge and belief that the information I provided is true and that I declare
U ECU
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 1111 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 CITYJb ~ C. Masterson 25. A. SOLEMNIZATION PERIOD BEGINS
NAME (PRINT)
21. SIGNATURE OF GROOM ~
w
en
z
w
o
::i
r-^-.
{ SEAL }
'-v-I
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
YEAR
MONTH
DAY
YEAR
07/11/200
DATE
appinger Falls, NY 12590
SIGNATURE ~
MAIL!e 1Vfl~
2006
09
09 2006
CITYITOWN
26. SOLEMNIZATION OCCURRED
TIME MO. DAY YEAR
'J ,.1..1'\ AM
Q'::U 07
STATE ZIP
27. TYPE OF CEREMONY
o ~L1GIOUS 1 0 CIVIL
9 0 OTHER, SPECIFY
STREET
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER-
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
,~
'2C4
w
t; 29. OFFICIAN~ (\."~' . \- ~_\
~ NAME (PRINT) I . t y \~ ~; . Q\C>
!:!: SIGNATURE~ ~ '-c)_H
to- MAILING ADDRESS I l \ 1_
O:w '1=>. o. ~Clt ..,-.;2 B t::1Qt' e we l \ :rd.
STREET CITYfTOWN
o
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY1M+che.55
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY fA ~T hSf!j(I.tt....
TITLE ~o MA ,.:) CA-r7+o U c fk,f$/.
DATE JLJl.) I if-, 2-<:0'"
New Y'O~k.. 1,;)..533
STATE ZIP
31. WITNESS TO CEREMONY
NAME (PRINT)
SIGNATURE~
DOH-9B (0312006)
~
NAME (PRINT)
SIGNATURE