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51 A 1E OF NEW YORK I STATE FILE NUMBER I
Dutchess (THIS SPACE FOR STA TE USE ONL Y)
COUNTY DEPARTMENT OF HEALTH
CITY,<Ir<lWN Wappinger / q} ?(,)o~
DISTRICT 1368 AFFIDA VIT, LICENSE and
NUMBER
REGISTER 162 CERTIFICATE OF
NUMBER
MARRIAGE Lo SUPPLEMENTAL FILE ~
FROM THE GROOM FROM THE BRIDE
,. A. FULL NAME Lawrence Wayne Way 1,. A. FULL NAME Tracy Lyn Yerks
FIRST MIDDLE CURRENT SURNAME FIRST MIDDLE CURRENT SURNAME
B BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT
C. SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D. SOCIAL SECURITY NUMBER
2. RESIDENCEA. New York B. Dutchess
/STA'Q;. (COUNTY)
C. CHECK ONE :1\. CITY _ TOWN _ VILLAGE
~~~CIFY Beacon
17A No. Brett St.
WAY
133-56-3334
060-54-9685
C. SURNAME AFTER MARRIAGE
,OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER
12. RESIDENCE A. New York B Dutchess
(STATE) . (COUNTY)
IX CITY 0 TOWN == VILLAGE
Beacon
D STRm ADDRESS 17 A No. Brett St.
C. CHECK ONE
AND
SPECiFY
O. STREET ADDRESS
ZIP 12508
ZIP 12508
E. IS RESIDENCE WITHiN liMITS OF CITY OR INCORPORATED VILLAGE? Kl YES [j NO
Nov. /21 /1968
MONTH DAY YEAR
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? Xl YES ~ NO
13.A. AGE 24 13.B.DATEOFBIRTH Nov. /13 /-1975
MONTH DAY YEAR
3. A. AGE
31
3B. DATE OF BIRTH
4. EMPLOYMENT
14. EMPLOYMENT
A. USUAL OCCUPATION NYS Correction Officer A. USUAL OCCUPATION DA Operator
B. TYPE OF INDUSTRY OR BUSINESS Fishkill Correc. Facil' ty B. TYPE OF INDUSTRY OR BUSINESS Verizon
5 PLACE OF BIRTH Cold Spring, New York 15. PLACE OF BIRTH Cold Spring, New York
(CITY. STATE/COUNTRY IF NOT USA) (CITY, STATE/COUNTRY IF NOT USA)
6. FATHER
A. NAME
B. COUNTRY OF BIRTH
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Lawrence Gale Way
USA
16. FATHER
A. NAME Aaron Henry Yerks
B. COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Maria Cecilia Scolaro
B. COUNTRY OF BIRTH USA
lB. NUMBER OF THIS MARRIAGE First
Sheila Marie Nenni
USA
8. NUMBER OF THIS MARRIAGE
First
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
19. PREVIOUS MARRIAGES
A, NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
DEATH
B. HOW DID LAST MARRIAGE :ND? 3) = DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) = DEATH
8. HOW DID LAST MARRIAGE END? (3)::::: DIVORCE
v. DATE ..AST MARRIAGE ENDED?
31 = ANNULMENT
/ /
[21 = DEATH
MONTH DAY
D. ARE ANY FORMER SPOUSE,SI ALIVE? = YES 0 NO
10. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PUACE ISSUED AGAINST WHOM
(MONTH. DAY, YEARI CITY, STATECOUNTRY, IF NOT USA) SELF SPOUSE
YEAR
MONTH DAY
J. ARE ANY FORMER SPOUSE(S) ALIVE? = YES = NO
20. 'F PREVICUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PUACE ISSUED AGAINST WHOM
MONTH. DAY. YEAR) (CITY, STATEiCOUNTRY. IF NOT USAI SELF SPOUSE
YEAR
1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, t
as to my right to enter into the manta
21 . SIGNATURE OF GROOM.
o
o
o
w
en
z
w
(,)
::;
22. SIGNATURE OF BRIDE.
. ;_' NAME
23. ~: DATE Sept. 8, 2000
This license authorizes the marriage in New York ate of the bride and groom named above by any person authorized by New York Domestic
Relations Law ~11 to pertorm marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
= If checked, this license is to be used onl for the purpose of a second or subsequent ceremony.
24. TOWN OR CITY CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
NAME ,PRINT) a 'ne Town Clerk
DATE 9/8/00
12590
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
~
{ SEAL }
'-.-I
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
SIGNATURE
M~~NGB~'5rE
S E
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT THE TIME ANO
PLACE INDICA TED.
AM
3 : 00 PM
ers Falls,
I rr N
26. SOLEMNIZATION OCCURRED
1M DAY Y R
NY
9
9
00
11
7
00
T T
27. TYPE OF CEREMONY
o ~~'GIOUS
!!~
CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK 8. COUNTY ~
C.
9 0 OTHER. SPECIFY
SPECIFY
o TOWN OF:: VILLAGE OF
g~A ~~. .
5
NAME (PRINT)
SIGNATUR
DOH-98 (
NAME (PRINT)
SIGNATURE.