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COUNTY Dutchess
CITYiTOWN Wappinger
~~~~~c~ 1368
~5~liJ~R 141
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
William 1. Barrack
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONLY)
I
{)inti
q..({.C'~
L 0 SUPPLEMENTAL FILE
-.J
1 A. FULL NAME
FROM THE BRIDE
Marie A. Mercorella
FIRST MIDDLE CURRENT SURNAME
B BIRTH NAME (MAIDEN NAME), IF DIFFERENT Locke
c. SURNAME AFTER MARRIAGE Barrack
(OPTIONAL. SEE REVERSE) 132 42 8171
D. SOCIAL SECURITY NUMBER --
12 RESIDENCE ANY B. Dutchess
(STAr~) (COUNTY)
C. CHECK ONE ~ CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
D STREET ADDRESS 14 No, Chestnut Street ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? ti YES 0 NO
03 /10 /1950
11. A. FULL NAME
FIRST
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE) 115 50 5471
D SOCIAL SECURITY NUMBER --
2. RESIDENCE ANY B. Dutchess
(ST~~) (COUNTY)
C. CHECK ONE r:J CITY 0 TOWN 0 VILLAGE
~~~CIFY Beacon
D STREET ADDRESS 14 No. Chestnut street ZIP 12508
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? tl' YES 0 NO
11 / 11 / 195
MONTH DAY YEAR
13. A. AGE 52
13.B. DATE OF BIRTH
3 A. AGE 44
MONTH
DAY
YEAR
3B. DATE OF BIRTH
14. EMPLOYMENT
A. USUAL OCCUPATION Nurse
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTH Poughkeepsie, New York
(CITY, STATE/COUNTRY IF NOT USA)
16. FATHER
A. NAME David John Locke, Jr,
B. COUNTRY OF BIRTH USA
17. MOTHER
A MAIDEN NAME Norma E, Pantin
B. COUNTRY OF BIRTH China
18. NUMBER OF THIS MARRIAGE 2
4. EMPLOYMENT
A USUAL OCCUPATION Auto Mechanic
B. TYPE OF INDUSTRY OR BUSINESS Own Business
5. PLACE OF BIRTH Beacon, New York
(CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME William J. Barrack
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Dawn Duro
B. COUNTRY OF BIRTH USA
8 NUMBER OF THIS MARRIAGE 2
DEATH
o
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
DEATH
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9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
1 0
~ ~
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT (90 DEATH B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 0 ANNULMENT ~ 0 DEATH
C. DATE LAST MARRIAGE ENDED? 08 / 14 / 1 96 C. DATE LAST MARRIAGE ENDED? 04 / 11 / 1 78
MONTI-\; DAY YEAR MONTI-\;' DAY YEAR
o 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, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE (MONTH, DAY, YEAR) (CITY LSTATE/COUNTRY, IF NOT USA) SELF SPOUSE
08/14/1996 Poughkeepsie, New York r!f 1ST 04/11/1978 Dutcuess Co., New York 0 rf
o ~D 0 0
o 3RD 0 0
o 4TH 0 0
belief thatt information I provided is true and that I declare that no legal impediment exists
22. SIGNATUR~OF BRIDE ~ (JA[P .{:1 fYJ(j j.A ..vl...-tJ..fld .
UWc~NAME
09/04/2002
DATE
by New York Domestic
21. SIGNATURE OF GROOM ~
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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 CIl): CLEflK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) l:iIOr_la J.
{ ~' QQ/04/2002 TIME MONTH YEAR
SEAL SIGNATURE ~ DATE
'-v-' M~(jG~em~bush Rd, Wa ails, NY 12590 01'.11 ~~ 09 05 200
STREET STATE ZIP
I CERTIFY THAT I SOLEMNIZEO 27. TYPE OF CEREMONY
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME AND
PLACE INDICATED.
11
03 2002
MONTH
YEAR
28. PLACE WHERE MARRIAGE OCCURRED
o 0 RELIGIOUS
9 0 OTHER, SPECIFY
1~ CIVIL
A. STATE NEW YORK B. COUNTyh rcf"Gs'\
C. LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
29. OFFICIANT
NAME (PRINT)
TITLE lY./lCte ~L$;a #;JCjj
DATE (Sep7, I/f; ~2-
pJlfpp/l./6F-i3t<.S" M.us ~. /;2..;;'" 0
CITYiTOWN STATE
o CITY OF JK TOWN OF 0 VILLAGE OF
SPECIFY ~,t(f('c~ fJ5'/~
SIGNATURE ~
MAILING ORE
'ES
STREET
30 WITNESS TO~C REMONY
NAME (PRINT) ---12AJ IIJ.-'/)
SIGNATURE~ ~ ~,
DOH.98 (11/98)
31.
~iKP
SIGNATURE ~