Marriage Certificate - Bolden, Deelaney L_11/16/2005i ram�a�e._:+e q •
"°'"'�°"eoib" STATE OF INDIA� ` ' '
N.w �.�a, �wonr No. _ —
""' '' APPLICATION FOR MARRIAGE LICENSE File� _��
GIBSON COUNTY
.� IC 31 - 7- 9- �. Fumishing false Infortnatlon u n a I In for Ilcense. Date o Applic—f a�io� -
, A person who knowingly furnishes lalse Infor� li nPlo a9clerk ol the ppliCan� 50 > No ❑ Yes ❑
circult court when Ihe person applies lor a marrlage Ilcense under �� Female A
I� No, Medical Examination or Report J�ated
, 31 - 7- 3 commits a Class D felony.
Name of Physician .n _ l� ,
Name
oam a et;n
PrevbvslAatla151�N5: NeverMarrep❑ )p No.olPrevbusl:arrlags\yr '
Lasi Martuge EntleE By: OeaN ❑ p„
o¢e O Annvlm¢nl❑ Dala
. �ata d E'vV� vetlOeC py ❑ gy�� Ce Ilcala �yyr (SPK�y)
��4��`� �V\ �
t. 'VS you rcw m nave yvu evar Eeen aahxlpeU b Ee ol unseurq rty`q7 Ho ,y 1
Ilansxgry as,- y� YesO
- Y �sllieaEj�pi�¢lionpeenremovpe7
2. �re No ❑ Yes ❑
you relateE b Ne lemale appp��� cbsu Vian s¢�onp �u�5N7 ���[[['''���
7. A�e au N�/�/ �es O
� �w�m�WWPMG01d�dkplpf��pvProei �r
� �. Ate )�w row y�pp� y�g ��IluaMa 01 d ndrep4 Eruap � �NO 1� Ves O
i llst ur M rumes ol e tl /�
^�' �ye"eerc��uCren.
Z
� 6. plFwnmeol �—_�1
n appOCanl'sialher
� lil aOOpIpE. Qs� �yp0 We Parenls pry�.
a RMqence0lWUy� II �{�
( OeceaseE, so smie) ..(�
&�W Vu ol lamer (Sa�e or lomign cwnlry� __
(�)F"�"mkenNmsolappikan�'smotne �
(II e0opleE. f¢I n�py�.e Peeanis pryy �
Rxilerce ol mallier (Y Oecease0. so stale) � �M • —
&�Omca ol molMr (SWIe or larelgn wun�y) 1 I 1/ SG�\� �_I
�•:'_��-'""" l_—�
� ���� e �" ACHNOi+l�EDGMENT
9 tuve rxeived iNOmulirn �egartivg ��eraus commu�ticaple Grseases
I Nal are smualy ry rqmii�� a�q a Osl ol Ihn i
y��a ���a� � al sites lor I�e vir�s ' causes AIDS (a[puireC
I Syrafwe ol Apdcant � L- j _ n �
�e above applrant lus ppJectaE lo vent�viy OY �1� or allirma�bn or si
Mk+nMeCgmenl p�use ol religious beGels. 9^a�ure lo Ihe above
GImMOICq�i_ _
Lamry
Sq�roc
ruew qcaeu
�a�e
� I sweatlalfvm Wi Ne Wy�yp� 9pe�
� ss. y� Nis appliwrypn Is trua aM cortect.
n
Ck�k o1.Ne Gipsan �IrcWl Lourt
CONSENT pF PqRENTS, PAqENi, OR GUARD, I
Wa. vy µi�anls ol Nis app�pan�. nereoY 9ive conseni lo� mis marriaqe. II ony �e pawm sgns.
SUIa lac�s wt�icA �yke Ne wnsenl pi lNe olne� paienl unnecessary
_ ��
Siilp OI IroiiN '
55.
Abtlror ID �
io .
SWSC+�OeC ettl �wom lo pebre me Ihk
— oay ol _
Clerk
Nart�e
F�c�e o� ehm
$lalus: Na�+ar
A
OR No.olPeevrous
Lasl Marrlage EnEeG BY: Dealn ❑ qw�ce ❑ A�
�m¢n� ❑ Dale
�ata ol p'vll� verilleE by: ❑ BYib �erl0ica�e � ONer (Spetlly)
I 1 °%Q �
1. AmyounoworfuveyoveverpeanaOjWqaCbpeolunsoyripmupp No�
II an 1 es o
swer s yes; tus tne aE'ryEica(W� yro� removed?
2. A�B � ra41eG lo No V!s C
Y° I�e ma�e aov�m cbsar uen sgcorq �p�y�� ��(%
�. /veyoumw�eyerityin;ry�enceolanakolq�Kpaveraga? o�"" Yes�
� ves ❑
d. Ne you row iWe� Ne Inlluence ol a rercotic drug7
4 �sl Ne iW ves o
names ol any EepenEent cMp�en_ _
Yea�
6. (a) F W��y ol app�ni's IaNer
(il etloo�ae.4s� p�ouie Farents Oeuy� ,
ReSWenca ol G;nar QI EeceaseE, m sUte) �
&tlhplace o1laNer (Stale or loregn cov'nW/ �
(E)FU0 maben n�me ol ap0acanfs mol�e��
(II atloole0, psl AEOO We Paeenis ONy)
ResiEerrcn W moNU (il tlacease0, w sfale) _
Bltl�play ol rsqNer (Stale ar lorelgn �pypyyl
ACKNOWLEDGMENT
� ackrwwle0ge �hal 1 have receivetl inlorma�ion regarGny a
�hat a�e sexuy • trar rr//fftt��tltl anE ylist ol Ne Iesl i �p� �
L�vnuna tlefrcie��Nb��L(.,� '} �e .. I
SignaWre of Aoo�� i Yti�. l/ (��(c�.. �L II
us communir.yble diseases
Ihal use $ (y��w��
/�
Da' '�
T�? above appticanl las o0jeqed lo verityi�9 py oaN w allir
a�^^uMietlgmem becausa o1 rei' ^��O^ w�9r+a�ure to ine above
�grous beliels.
Gle�k 01 Cqur
Daie
Stal Ileql
CounH ol_ �� 1 swea4a14�m Inal Ne aoemallon ghen
�T-"—iF � u. m�tisawrr�u„�:�,.....�_____"
SlgneE
nmress
ine GiDSOn �trcW
CONSENT OF PARENTS, PARENT, OR Gl1Ar �q��
Lve. ilie Cerenis of ues apdkam. �meDY 9�e ro�em I°� Ws nortiage. II oNy ore paeeN syns.
sia�e lac6 whicn maye Ine consem ol �ne o�ner oarem uhnecessary
$tale OI IMiara �
1 ss.
Faser
ID •
MoO+ee
ID •
SWU+'EMarqswornb0eloiemeWS�payol '_
COMPLETE IF MAqRIAGE UCENSE ISSUED BY ORDER OF COURT: A marnage license having been refused fo the a6ove.nzmed.partiescthe
and liled in County _Court, by written order issued
. authorizes and directs the issuance of a marriann r o.,�e ,,. �.._ _�_.
�t�CURN O�,�IpgH�pC�, �,�CCNSC AiVU �L�RRL�GC CERTI�ICA7'E cV ��"'es.
1 certiJy rh J rher �vns filed in my oJf�e n innrringe (iceiise issuer l� the Clerk oj rlir C(ra it Cotv oj Grbson Couniy, /nd(ttnn.
da��d_ ' 3 �
�a? . ntrdtor' .ing (h<• nmf�c oj
C� �ai�v
/ju�� �e cer i v tlia� t/ jof , viir irtnrrit+ge cer�ificnte �vns frle�( i�r u�y ol�- e:
�/. �
� (nnniel. �ertify rha�n
�+_Counrv. b�rfrunn. (dateJ. at — rn
�� (stnre), m+d °j Counry,
--�� (s�nte) �rere innrried Gy n�c ;i,s �uthori: ed mider a n�arrrnge lrcense tl� t ivas �i�ssn � Gti� the Clerk of rlecr,
Circuir Co�vr ojGiGsni Coiun �. G liai i. da�ed 3 ��y .
SigiieA 6y: � _
Filed n�id recorded ii� accordnnce wi�h �hc lmvs oj ie S(n�e o(L�drann n,� �i1.0-v1 `/��'���-.n. � . �.
., ,,,..,. , �
vn,snn t,.vctn! Cnur!
Clerk
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