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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
P.
MIDDLE
1ST
2ND
o 3RD
CJ r 4TH
that to the best of my knowledge and belief that the Information! provided is tr;J6 and that I ~c(ja thaJ n
estate. / '! \
I " " ,
22. SIGNATURE CF BRIDE ~"= I' :
L EC ~E~TNAME I
23. k ,\ DATE -Sept.
This license authorizes the marriage in New' York State of the bride and groom named above by any person authorized by New York
Relations Law ~11 to perform marriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
[J If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
24. TOWN OR CLERK 25. A. SOLEMNIZATION PERIOD BEGINS
ine H. Town Clerk
DATE 9/19/00
NY 12590
STATE
27. TYPE OF CEREMONY
o [)A(ELlGIOUS
(J() 9 0 OTHER. SPECIFY
COUNTY
25fmoWN
DISTRICT
NUMBE R
REGISTER
NUMBER
Dutchess
Wappinger
1368
173
A. FUll NAME
Scott
FIRST
VanZandt
CURRENT SURNAME
<l.
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL. SEE REVERSE)
D SOCIAL SECURITY NUMBER
2 RESIDENCE A. N ew Yo r k
(STATE,
= CITY c:f{TOWN = VILLAGE
Poughkeepsie
19 Taconic St.
058-72-1948
B.
Dutchess
(COUNTY)
C CHECK ONE
AND
SPEC:FY
ZIP 12603
D. STREET ADDRESS
E. IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VilLAGE? 0 YES LX NO
3. A. AGE 2 C; 3B DATE OF BIRTH Nnv / OR /l q 7 Q.
MONTH DAY YEAR
4. EMPLOYMENT
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A. USUAL OCCUPATION Accountant
B. TYPE OF INDUSTRY OR BUSINESS HVFClT
5. PLACE OF BIRTH ICll.~~l~~~~~~V:r~U~A) New York
6. FATHER
A. NAME Wayne T. VanZandt
B COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME
B. COUNTRY OF BIRTH
Patricia
USA
First
A. Antonelli
8. NUMBER OF THIS MARRIAGE
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
DEATH
B. HOW DID LAST MARRIAGE END? 131 = DIVORCE
C. DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) [! DEATH
MONTH DAY YEAR
D. ARE~NY FORMER SPOUSE IS) ALIVE? = YES [] NO
~o. 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
1ST
2ND
3RD
4TH
I. being duly sworn. depose and
as to my right to enter into the arri
CJ
21. SIGNATURE OF GROOM ~
W
en
z
W
o
::;j
,-'-..
{ SEAL }
'-v-I
NAME (PRINT)
SIGNATURE ~
MAILING ADDRESS
PO Box 324.
STREET
I CERTIFY THAT: SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DA TE AND AT THE TIME AND
PLACE INDICA TED.
29. OFFICIANT R r: V 12~~ I... JJ .J._
NAME (PRINT) ..---:~. c.. IT , ~ ,-"D r, '-
SIGNATURE ~ . ~
MAILING ADgflESS , /7
o Y e/l..'Z7r:- /L;
STREET
30. WITNESS TO CEREMONY
NAME (PRINT)~ ~ / ~!('1~~? Ct V)1j.}-
SIGNATURE ~ 7#U.Jn1tJ-1!.!l ~df
TITLE
,.-"7(;;0'
STATE
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
I
L 0 SUPPLEMENTAL FILE
~
11. A. FULL NAME
FROM THE BRIDE
L.
MIDDLE
Gall a~h~r
CURRENT S NAME
Arn~
FIRST
B. BIRTH NAME MAIDEN NAME',. IF DIFFERENT
C. CHECK ONE
AND
SPECIFY
Van Zandt
076-60-9293
B Dutchess
, COUNTY)
o VILLAGE
C. SURNAME AFTER MARRIAGE
,OPTIONAL. SEE REVERSE)
a. SOCIAL SECLRITY NUMBER
12. RESIDENCE.~ New York
,STATE)
C CITY CKTOWN
Fi l':hki 11
771 Ol':hnrne Hi 11
Rcl
ZIP ] 2 C; 74
o STREET ADDRESS
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VilLAGE? [] YES X NO
13.A. AGE 71 13.B.DATEOFBIRTH Fpn /71 /lq77
MONTH DAY YEAR
14. EMPLOYMENT
A. USUAL OCCUPATION Real E~tate
B. TYPE OF INDUSTRY OR BUSINESS HVFCTT
15. PLACE OF BIRTH PmHrhkeenl':ie. New Ynrk
(CITY, STA'fEiCOUNTRTIF NOT USA)
16. FATHER
A. NAME. Michael J. Gallagher
B. COUNTRY OF BIRTH TJSA
17. MOTHER
A. MAIDEN NAME Karen L. Secchia
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE
First
19. PREVIOUS MARRIAGES
A. NUMBER CF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVil ANNULMENT
DEATH
B. HOW DID L~S- 'AARRIAGE END? (31 C DIVORCE
v DATE LAST MARRIAGE ENDED?
31 = ANNULMENT
/ /
2' = DE.~TY
MONTH ~AY YEAR
D. ARE .~NY FORMER SPOUSE(S) ALIVE? = YES = NO
20. IF PREVICUScv DIVORCED OR ANNULED. PROVIDE -HE FOLLOWING INFORMATiCN
DATE OF DECREE PLACE ISSUED AGAINST WHOM
,MONTH. DAY. YEAR) ,CITY. STATE/COUNTRY. IF ~OT USA) SELF SPOUSE
c
19,2000
Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
TIME
MONTH
DAY
YEAR
MONTH
DAY
YEAR
ZIP
9: 05 AM
PM
00
09
20
00
11
18
28. PLACE WHERE MARRIAGE OCCURRED
1 = CIVIL
A. STATE NEW YORK B. COUNTY DU7c.ttt.Jf
C.
rrte S" T
ID/7/eo
I ,I
VilLAGE OF
SPECIFY
,,~ t.
ZIP
31 WITNESS TO j:EREMONY
NAME (PRINT) \;\ ~ \"'\"\ 'D? '\ ~I 1J 0W Ie '-J
SIGNATURE ~ ~_ Y^n \ \):-. ~ \) f;'\ ~ J \.~-\-