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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Thomas Af'draw PamJf~r.i
FIRST MIDDLE CURRENT SURNAME
COUNTY Dutchess
CITY /TOWN Wappinger
~~J~kCRT 1368
~5~I~J~R 62
1. A. FULL NAME
Q.
N
B BIRTH NAME, IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE)
D. SOCIAL SECURITY NUMBER 140- 7.4-7'17
2. RESIDENCE A. N v B. nlltr.ha~s
('tf ATE) (COUNTY)
C. CHECK ONE 0 CITY ~ TOWN 0 VILLAGE
AND Phk .
SPECIFY 011 eap~le
D. STREET ADDRESS l' Toomay nrive ZIP 12603
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILlAGE? 0 YES ~ NO
3. A AGE 39 38. DATE OF BIRTH ---.;\J~ / \1;, /1!Jf5
4. EMPLOYMENT
A. USUAL OCCUPATION ~ar:penter
B. TYPE OF INDUSTRY OR BUSINESS Bronkg ClHdom
5. PLACE OF BIRTH ~~lmT ,!~rk
6. FATHER
A. NAME ~8ntino PamJr.r.i
B. COUNTRY OF BIRTH II S A
7. MOTHER
A. MAIDEN NAME Loretta Gailardet
8. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARRIAGE 1
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
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(3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
FROM THE BRIDE
11. A. FULL NAME Karen Marie Woodward
FIRST MIDDLE
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT Pagano
C. SURNAME AFTER MARRIAGE Perrucci
(OPTIONAL - SEE REVERSE) 062-42 2229
D. SOCIAL SECURITY NUMBER -
12 RESIDENCE A. N Y B Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITY r! TOWN 0 VILLAGE
AND P hk .
SPECIFY ou eepsle
D. STREET ADDRESS 12 Toomey Drive
CURRENT SURNAME
ZIP 12603
DYES~NO
18'51
YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE?
13. A. AGE 5.4 13.8. DATE OF BIRTH 05 .-04
MONTH DAY
14. EMPLOYMENT
A. USUAL OCCUPATION Computer I S Manaoer
B. TYPE OF INDUSTRY OR BUSINESS Chemprene, Inc.
15. PLACE OF BIRTH Yonkers New York
(CITY, STATE/tt,UNTRY IF NOT USA)
16. FATHER
A. NAME Michael Pagano
8. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Halan Maria Rayer
8. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 4
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
3 0
8. HOW DID LAST MARRIAGE END? (31 cfDIVORCE (3) 0 ANNULMENT (2) D DEATH
C DATE LAST MARRIAGE ENDED? 01 / 21 / 2003
MONT~ DAY YEAR
D. ARE ANY FORMER SPOUSE(S) ALIVE? LT YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
1110211973 Yonkers, New York rf
07130/1982 Yonkers, New York r!f
01/23/2003 PoughkeepSie. New York r!f
DEATH
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nd belief that the information I provided is true a
23. SUBSCRIBED AND SWORN TO 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) JO~~
SEAL SIGNATURE ~ ,c:rn~ DATE 07/1112005
MAILING ADDRESS 08:39AM
'-v-I STR~9 Middlebush Rd, WappjIWl~!lalls, NXAT~2590 ZIP PM 07
~~~R~~~Ri~~~ IO~O~~~N~~~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME MO. DAY YEAR 0 0 RELIGIOUS 1 b' CIVIL
DATE AND AT THE TIME AND /'
PLACE INDICATED. 9 0 OTHER, SPECIFY
DATE
by New York Domestic
TIME
MONTH
YEAR
B. HOW DID LAST MARRIAGE END?
C. DATE LAST MARRIAGE ENDED?
YEAR
MONTH
YEAR
MONTH DAY
D. ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
21. SIGNATURE OF GROOM ~
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DAY
12
2005
09
09 2005
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTy.Du.~
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF ~WN OF 0 VILLAGE OF
SPECIFY P~Wft.e.~Q/-€"'-
ZIP
WITNESS TO CER'1'4eNY.... l j f. '
NAME (PRINT) J d.)C 6\ C e r rCJ C t
SIGNATURE ~ D ~__ ---