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CITYrrOWNWappinger
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REGISTEfb6
NUMBER ..:>
STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFADAVIT,UCENSEand
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
Damon Jon Botelho
MIDDLE CURRENT SURNAME
I
STATE FILE NUMBER
(THIS SPACE FOR STATE USE ONL Y)
-,
L 0 SUPPLEMENTAL FILE
FROM THE BRIDE
Christin Sarah Gleason
~
1. A. FULL NAME
11. A. FULL NAME
FIRST
MIDDLE
CURRENT SURNAME
FIRST
Q.
IQ
B. BIRTH NAME. IF DIFFERENT
B. BIRTH NAME (MAIDEN NAME), IF DIFFERENT
C. SURNAME AFTER MARRIAG~otelho
(OPTIONAL - SEE REVERSS87 -78-3485
D. SOCIAL SECURITY NUMBER
12. RESIDENCE NY put chess
(STATE) oJ! (COUNTY)
C. CHECK ONE P CITY" 0 TOWN 0 VILLAGE
~~~CI~ast Flshkill
D. STREETADDRESF3 Route 210
'12582
ZIP
C. SURNAME AFTER MARRIAGE
(OPTIONAL' SEE REVERSGl,.
D. SOCIAL SECURITY NUMBER u52-74-6090
2. RESIDENCE ANY B. Dutchess
(STATE) (COUNTY)
C. CHECK ONE 0 CITW'\:] TOWN 0 VILLAGE
AND W .
SPECIFY applnger
D. STREET ADDRESS29 Kent Rd ZIP 12590
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YEtO NO
07 /07 /1980
MONTH DAY YEAR
~
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YI~~5ND
13. A. AG!24 3B. DATE OF BIRTH 06 ~ ~
MONTH DAY YEAR
3. A. AGE29
3B. DATE OF BIRTH
4. EMPLOYMENT
A. USUAL OCCUPATION Correction Officer
B. TYPE OF INDUSTRY OR BUSINESS Corrections
5. PLACE OF BIRTHEouahkeepsie. Ny
(CITY.1'TATE I COUNTRY IF NOT USA)
6. FATHER
A. NAME .Jnhn A Botelho
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Karen Rosemary Butler
B. COUNTRY OF BIRTH USA
8. NUMBER OF THIS MARF,lIAGE 1
14. EMPLOYMENT
A. USUAL OCCUPATIO~vionics Technician
B. TYPE OF INDUSTRY OR BUSINEsf'Vlatlon
15. PLACE OF BIRnfoughkeepsle, Ny
(CITY, STATE / COUNTRY IF NOT USA)
16. FATHER
A. NAMeGharles Kenneth Gleason
'B. COUNTRY OF BIRT~ S A
17. MOTHER
A. MAIDEN NAMEGretchen Scott Rieg
B. COUNTRY OF BIRT~ S A
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES .
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DOORCE CIVIL A8NULMENT
DCfTH
9. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
n 0
DEATH
o
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE (3) 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, STATEICOUNTAY. IF NOT USA) SELF SPOUSE
(3) 0 ANNULMENT (2) 0 DEATH
/ /
..~ YEAR
B. HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
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) (CITYICOUNTY, STATElCOUNTRY, IF NOT USA) SELF SPOUSE
o 0 1ST
o 0 2ND
o 0 3RD
o 0 4TH
and belief that the information I provided is tru
o 0
o 0
o 0
o 0
no legal impediment exists
US C RR
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 ~11to 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) n C. Maste son
TIME MONTH YEAR
SEAL SIGNATURE~ DATE 04/23/2010
MAILING ADDRESS
'-v-I' in ers Falls NY 12590
STREET CITYITOWN STATE ZIP
~~:R~~RT~~~ 10~O!#.~N~Zi~ 26. SOLEMNIZATION OCCURRED 27. TYPE OF CEREMONY
SONS NAMED ABOVE ON THE TIME M . AY :fEAR 0 III RELIGIOUS
DATE AND AT THE TIME AND 5",1\ AM
PLACE INDICATED...;J(,J 9 0 OTHER, SPECIFY
NAME
04/23/2010
DATE
by New York Domestic
25. B. SOLEMNIZATION PERIOD
ENDS AT MIDNIGHT ON:
MONTH
DAY
YEAR
12:39:~ 04
24
2010
06
22 2010
10 CIVIL
28. PLACE WHERE MARRIAGE OCCURRED
A. STATE NEW YORK B. COUNTY']?trIIt!'S~
C. .LOCATION OF CEREMONY
(CHECK ONE AND SPECIFY)
o CITY OF 5(J TOWN OF 0 VILLAGE OF
SPECIFY ~r~k~ep;f'
NAME (PRINT)
SIGNATURE~
NAME (PRINT)
SIGNATURE~