Marriage Certificate - Bolton, Cheryl L_10/16/2001i
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APP`�STATE OF INDIANA ho.
ION FOR MARRIAGE LIC�.�E Fi�e
GIBSON COUNTY �ate f Application—�
'� _
: IC�31 - 7- 9- 1. Furnishing false Informatlon upon apptying for Ilcense.
A person who knowingly furnishes faise information to a clerk of the Female AppliCBnt 50 > No ❑ Yes ❑ %
_circuit court when the person applies for a marriage license under IC If No, Medical Exartj ia'on or ort Dated �'� '� �(
3l - 7- 3 commits-a Class D felony. i Name of Physician �` d
uame
_Daie ol BM
FL
R¢vbtKManld15taWS- NeverAfarrb4CV[1R No.al
N-
,r� name � y�F
U L
Year Date ol'ciM _
La9 Marzage EiMea 6y: DeaUi ❑ Divo¢e ❑ Annulmem ❑ ad:e
Da:P d GM vPnli¢0 OY .�—' di(rt� G2• 1¢ G�jJqr �Spttily�
'(���. �R ��C /
1. Are yvu now or tave you eve� been eEjW peE �o be o� unsoarv] min0? 6[� V¢5 O
I�anSxeris7es: tN5N2a0jVOK24pnppinr0mJV9Ci N0���0//J YlS�
2. Are you ielale� to Pie lemd'e applicdnl cbser Uwn secorp cousin? Ncy Ves ❑
L7
3. Rre you rww u�er Ne iNNeMe ol an alminFC Eavarage? No� � Yes ❑
� 4 Are �rov rrow un0ee Ne vdlueMe ol a na¢otic Eruq? � Ves ❑
5. LiSt:M lull names ol any peperqem chNtlmn.
w
c�
z
`z_
Q 6. (a�'Wnameola0d���sfamn ^^ [1
a pla0oo�e0,tistA�ocweParentsOa�• N�' u�
¢
a �ieSUerce af :a�tre� W CeceaseC, so sia;e)
BvNphce al famer �S3te oe laieym m � �
�E�Fu4rmiCennam=alappticanismo ,c
(�Iado0�e0.IS�ACOptrreParen�s ly)
RPSqPT.2 01 rtqlf�p( [0 dEC2d5B�. SO S�d:2)
BtrmO�ce of moMee (Sale o� toregn wunvy)
ACKNOWLEDGMENT
I ac'.mwleage ;ha� I have � cervetl iNormalion regammg tlangerous mmmu�dq6le tliseases
mat ar= sexually tr �smin ana a list o� Vie test ss"--jjs to•}�N�= w,us tbal puses AIDS (acquired
vnmune tlefkiency n . � � ,{�^[� p ,�.,, � /�
SignaNre of Apdi. ----(L.1L�1� l� 6a[\/ )�V
The aoove a0vlicant nas
acinovAetlgmer.; bzwus�
Geek ol Cw�n �
Cqunry ol
SyneC
to venfying by oa;h w aYirmation or sigrayre to Ne above
Ns beliels.
55. VINIS
_ Dala
mal Ne iNarmation given
ian is true aM correcl.
Ne Gmmn Cuun1 Coun
CONSENT OF PARENTS, PARENT, OR GUAF�IAN "
YIe, Ne pa�en'S ot �nis applcan� ne�e0y give wttseN loe 0'i5 narziage. If pnry OnB Daient sgns,
s:ate laca nhicn maie tM1e cansent at tne olne� paren� vnnecessary
S�ale ol Inouna �
Caunp'o� ) ss.
Famee ID �
I.btrei ID � _
Se�ur.pe0 anC sxom m Ceb�a me Ns — aay ol ,_
Cle�k
Pre�+CU$Ma�iWStalust NeverMartiea�
� 1 Vear
�..Y � '
No. ot Aevous Mair¢grs —
Last Mareqge Entletl By: Oealn O Divorce ❑ Ann�M�ent ❑ Date
Oa�e o� buN v¢�JiBd ' ❑ BYIM1 C¢r4lica�E �er ( uty�'
1. Are ycu �ww a� �eve you evei been aCjutlge0 b Oe ol unsowk mina? u�i / Yes']
/ V
u answer c yes,-nas me aGuGin:wn Ceen eemovetl? Ko C�/ Yes �
2. qre you reb�e0 W i�e ma4 appGCant cbse� itmn se�nC wirtin? Yo2C. Yn O
3. Pre you row under Uie 4JUeae of an alcoM1olic Eeve2ge? t�a�' Yes O
a. Are you rrow under ihe in.".uence ol a narcoUC arug? No��jl'es O
5. l'¢I NP W0 r�amB6 Ot eny OepenaBnl CMqren.
6. (a) FNI name ol apqkanfs la�er I 1,1
(il a000��. �� AOOpOVe Paren5 ONy) y,!
Fasitlerce al IatM1er (il OxeaseE, w sta�e) _
EtrNdace ol �a�er ($ata oe breyn ar�n•,ry) .
�p�R�l maqen name ol apDf�anfs rtwN�
�f dQOpIQd, f151 lb00�< PdRpS �M�'�
Reskence ol rtq;�er (il EeceaseC, w stale) _
Birtnplaca o1 mot�er (50:e o� loregn coun:ry)
ACKNOWLEDGMENT
I a:knavledge �na� I nave receivetl intom�aion regartivg da�gemus commurdcabl_ d:seazes
tlrat are sexwM vansmilted. ariC a lis� ot �he Iesl siles tor Ne Mns Ihat wrsesMDSlabuired
� ' ``
iTe above appficant has objx;etl co ver�'ying by oav� w aN.'umation or signaNre tc tM abwe ~
ac'trowledgment becavse ol religious Oelie;s.
Cler: of Caurt Da:e
SU;eoHnG i� 1 /�'� ) IsveaqaL'umNalNeinlorr.pticngiven
Coun.y o� � / V' l.J � ss. ' p 05pypn a we aM wrrect.
V L,f:, ,. _..�: rA v 11: .��
New Ptltl�ess
Syqlll b pBtDi
Ne GDSOn Cvcua Ccun
CONSENT OF PARENTS, PAFENT, OP GUAFD�ih�
LYe. Ne �eren's o� Otls apqicant �are0y grve mnsent for mis martuqa. II pnty one parent signs.
sta;e IacLS w�Kh make 1�8 consent at Ne a:t�er Oaren� unnecasury
Sta;e oNnCUna )
Counry ol ) ss.
Supunpe0 eiM Sworn b El:Or! mB ttv5
io.
ID �
tlay ol . —
Geri
COMPLETE IF MARRIAGE LICENSE ISSUED BY ORDER OF COURT. A marriage license having been refused to the above named parties, the
County Court, by written orderissued
and filed in , authorizes and directs the issuance of a marriage license to the above named parties.
RI:'I'UR\ OF 1IARHlAGE LICENSE AND �1ARRIAGE CERTIFICATE
I certijy hn d ere iens Jiled in nn� ojjlce a�nnrringe license issued by e Cferk oj die Circuit Court oJ Gi6so�� Cottrit�'. Iiedimm.
dnted���l�. mtrhori�iny d�e nmrriage oj _� � a��d
1
�.�..o`Couiuc. /ndim�n,
�� (sta�e). m�d �
� (state) �re�e mnri�ied
Circuit Courr f�.,�bsyo/�� Cow%�� �. /n� ' rm. ated_
Signed byzs�3 / ! -
�ot+sJiled in m�• ojjice'
I cenif�� tlmt on .�D_L_(date), ar����
q _ oj� Counn�.
�f. ��.J of �c.� Cow�r��.
r�s muliori�ed mider a mnrringe licer�se that was issued bp the Clerk oj rhe
Filed m�d recorded iii nccarda�ice �rirh the fmvs ojthe Stale oj lndiunn on
(�date).
C(erk
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