Marriage Certificate - Allen, Jami L_6/19/2003n
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GmPrtxMeOBy � STATE OF INDIANA �
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"°"""°""'m°°" APPLICATION FOR MARRIAGE LICENSE
dIL]f-J.]
GIBSON COUNTY
IC 31 - 7- 9- 1. Fumishing false Infartretlon upon epprying for Ilcense.
A person who knowingly furnishes fatse information to a clerk of the
circuit court when the person applies for a marrlage Iicense under IC
37 - 7- 3 commits a Class D felony.
Nar.a
File
' / - 0
ate o Application e
Female Applicant 50 > No Yes ❑
If No, Medical Exam' tion Report Dated 9- � 1- �a
Name of Physician
�MALE APP�LICANT� � FEMALE APPLICANT
11NhO 11� (I�dst.. Name (�(� �.. . le
Dale ol BuN ��y(°Ah I_ Day � Q, � Veae I Da:e ol BWh
Place ol Birth (State a� brelgn muntry)
Prevbus Mariql StaM: Nevar MarrieE�OR No. ol Pmvbus Narzwpes
lasl Mamage EMeE 8y. DeaN ❑ �iwrca ❑ MIINrtMnI ❑ Da1e
Da;e o� �41� ven:leE Ey: ❑ BWf GlNlka�e 7�l�er (SplCdy)
�,:�c Q ,.,.��
1. Rra you now ar fuve you ever Ceen aEryCgeE �o Ec oi urrsourN rttinC? N�Yes ❑
�
II ensxe� Is yes,-1ms me aEryEkauon Cean rtmweE? Na ❑ Yes �
2. Are you rezleC b Ne lertvla a00���� cbser Vian samnE wusln? �' Yes ❑
3. Are yo� now unEer me Wluence ol an akotalc Eeverage7 N� Yes ❑
/
d. Are yov now unEe� Ne Inllvence ol a narcotic tlrug? No Yes O
i LISIIMIWIIdTlSOIi11YCCOPM!l11ChYC¢�.
��
6. �a�FWwr�ealeppf�nl'sht�er �
lil eEOptetl. �st AOOpWe Parenis ONy) —
ResiCence o� haNer (J Cecease0, so state) —
BIMpWCe a11a:t�ee (Stlh or �oreqn muntry) _
(p�F�ll meWen �ume ol app5cant's rtaNar
(II eEOp�eU. fal ACOptive Paren15 Only) �
ResiCer�ce o� mol�er (Y Eaceaud, so siate� _
BiMplare al molner (SIaR or foregn counVy)
I xknovAeOge Ihat I tuve r<
Nat are seRUaOy vaMmitled,
immuneGelitiencyryri0r e
Signature ol Applicani�
Pqce of B'vN (Sta�a ar lomign counvy)
�ay �(� ti 11 Year
Counry
Prtvbus Marital SIaNS: Never Martie�OR No. ol Peevbvs Marriages
Last MartlaBe EMeO 6y: Deain a orvo.ce o Arv�ulmen� ❑ bale
6ate o10'vN verilleE q� ecN CerluKare ❑ otlrer (SOeclry)
1.
2.
3.
5.
6.
/�0 yo� Mw 0� Ifdv! y0V eve� �een dtl�utlge0 b �C OI Utm��W rtvM? No �es �
II a�vtwer's yes; tas Me aCjv]iratlon bean removM? No a �es �
ara you ralaleE m Ine male appfimm cbser Rren secoM cous�n? N� Yes �
Are you naw urWe� t�e inMence ol an akolwf¢ Cevarage? No Ves ❑
Are you now uMer Na InfNance ot a mrco�c Orug? N�^w2/Yes ❑
L'a� Ne fuA romas ol eny deOeMen� chikre�n.^A
�`
(a) WG neme ol eppGCanfs fa�er
(II atlo0�eq ist AEOp•m ParenS ONy) J
Reskence al faurer (J Eeceased. so sfa's) , ^,,
BiMpb<e ol hNer (Sta:e cr loreign munvy) � V`�
(C�F�O maken name ol appf¢nfs moNe�
(II e0opte0, lisl Ptlop�v¢ Parer.S Ony)
ReslOenro ol moJia N 4eceaseC, m sta�e)
BIr1�Obce ol moNer (Sq;e or forelgn country)
crommurdcable d'aeases I acknowletlge i�ai I
A causes aIDS (arquireE that are senualy t2r
9. I I' O'f immune tleficiency r
Da;e t G cigraWre W APWicai
ACKNOWIEDGMENT
i in'ormatbn regarQing Eangerous mmmurdwWe Ciseases
lisl 01 the t t si�es lar I�e Nrvs t�at causes AIDS (acquired
� �� �6
� � Da:e �LZLL.
TM above apqirant has objecleC to ventying by wth or a(firmalqn ar sig(u;ure ro I�e above Tha above applicani Ims obj=c:M m veritying Dy oaN or atfuma;ion or signature to ih_ above
actrnwleCgment because ol re6gious be6ets. acknovAeEgment because al re6gbus beliets.
GerkolGouet Date GerkolCOUM ��e
Sa:e ol Intllana
SgneE
New ROOress
Nat Ne inlortna5on given
bn b We aM rorrect.
ol Ne GIEwn G¢iril Gaue
CONSENT OF PARENTS, PARENT, OR GUARDIAN
\'le. Ne paren3 0l Vvs appECnnl, �ereEy give mnsen� lor U�iS marzpge. Ii oNy ona �arent sigris,
nata tacis wnkn mahe Ne unsem oi tne amer parent umacenary
Sb:eallrquna �
r ���N�i � ss.
Fa:ner ID r
nwme, io. _
Su05aiEeC eM svom lo Oeb�e me Ihis _ tlay ol ,—
Qe�k
Sta�eollMU� 1 Iswearlallvmtl�atlnewomawn9�n
Counrys��._ ? /���ep� 's We and corrxl
/ \ Y. /�
�'�'��17i 1%
V
New ACEress , p � _
tne Gesrn Cucuv Co�n
CONSENT OF PARENTS. PAftENT, OR GUARDiAN
we, Ura paeanis ol UJS app&znL �ereAy gNe co�rtent for Cus im�rWge. II oNy one pareni sigen,
s01e lacts wMC� make tlie cansent ol Ne othae parent unnecessary
$p�e 01 IMwia )
fnunNnf _ 1 ��
Fat�er ID � —
Mo:l�m �D � —
SWSCriDeO an0 swom to Eetore me Nis — Cay al .
Glerk
COMPLETE IF MARRIAGE LICENSE ISSUED BY ORDER OF COURT. A marriage license having been refused [o the above named parties, the .
Couniy CouR, by written order issued
and filed in , authorizes and directs the issuance of a marriage license to the above named parties.
RETURN OFl11ARRIAGE LICENSEAND 117ARRIAGE CERTIFICATE
1 certify t at th re was fi(ed in my a�ce a marriage license issued b the C(erk of the Circttit Caurt of Gibson Counrv. India�ia.
dated , autho iling d e marriage of---T=i--� �-�pO-^ and
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n Q�GQ�.>
lfurth .r cert' hat ie follo�yjng � arr' ge ce t' �care was filed in my ajfic : /J� � �
/. � � iia�n ). certih� that o�i a� dnte)y. �atr� ��!�*�fi�
. —Counrv. lndinna. of��2+�� County.
�_(smre), and of—�ti� Counry.
e�,,.... (state) were married byp �� ne as puthorized under a marriage license tluit war issued by d�e C/erk of the .
Circuir Coltct ofGibsmiLountv. lndiana. dtueds4.l.� �� ��—
Signed by: _ai_GV' !i✓'aAzt.f_' �S..bi'!is� t e�� /_'�LL/o�0 (offi �a! designation)
Filed�and recarded in acco dnnce with rhe Imvs oJ the Smte of /ndiann ai 2--- (date).
Signe . ferk
i Gibson Circuit Court