Marriage Certificate - Bysarovich, Derek J_12/19/2003a
551
F«mP��r � STATEOFINDIANA • No.
Naaiv Suro Baam a
wic��'`i� APPLICATION FOR MARRIAGE LICENSE File
GIBSON COUNTY ��o�p�ic��
IC 31 - 7- 9- 1. Fumishing talse Information upon applyfng for Ilcense.
A person who knowingty fumishes false information to a clerk of the Female AppliCant 50 > NO ❑ Yes ❑
circuit court when the person applies for a marriage license under IC If No, MediCal Examination or Report Dated
31 - 7- 3 commits a Class D felony. NdmO Of PhySician ���� ¢�
MALE APPLICANT
Name �I /1 O
G�s+'
Daie ol BIM
�_ Race h(Sqte oe loregn coun
—�.
. " R nce AEEress Slree� F� Cly � Cpur � SO:e
. . � . o � � �. Y�iJ1 �A✓_ n-..,
PreviousMan3152:us: Neve�MartieOVOR No.olPrevbusMartiages_
Last htartiage EMM By Deam � Diwrce O AnnulmeM a Daia
Date d DiM vea5e0 �y. ❑ Birth Gertilicate O ONer (Specity)
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Name
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FEMALE APPLICANT
Stace
Previws ManW 53;us: Nevar MarzieE �(IJF No. ol Prevbus AAartuges �
lasi r.�amage Emea 6r oea:n ❑ oh�r�� nrvunmem o ozt ���2110�
1
Date of binh vertlieE oY �� �ry���e o O�er (Spetlry) ,
FIp YpV Iqw Of tNVp y0U Bv¢! �Qln 84�gB0 b �8 01 URSOUM rtY(YJ? Nppy VQS O 1. AIp y0U Mw 0! I13Vp y0U ¢v¢! �B¢n dtl�Udgetl to bP ol unSpuM IIIYIC? Np�C.\ Yes ❑
�
II answer is yes,- tus If�e aary�fa'von �een removeE? No � V¢s ❑ I� ansver's yes,- Ws Ne aQutliation been removeC? N Yes ❑
Rre you reta:etl b Ne Ierreie appG[ant cbser Wn secoM m�s'v:? No� Yes O 2 nre yov rek�ed �o �ne r�eb applkam cbser chan secoM cousin? No� Ves ❑
Are yo� mw wWe� tM in:l�enca of en akotnic Ceverage? No D' Yes ❑ 3. Are you row untler Ne iN' uence oi an akohoEC Ceverdge? No jF Ves O
Are you now vMe� Ne Wluerce ol a rorco:k Orug? N� Yes � a. Are yov eww unEer Na intluence oi a rmuuc Emg? No� Yes O
List Ne M rmr.�es o� aery tlepenCenl cNCren. 5. list Ne tW mmes ol any 0epen0ent ctuL'ren.
(a) FNI reme o� appfiranfs �aNer �
(II aEOO��. fst AEOptive PareMS QJy)
Restlerce ol hNee (il Ceceasetl, m state) —
BIMWace ot la•Jier (Sate or fore4� �unay) (
�elFw maae� �:,e oi mosm�r: �oma� �i
pf a0ooso, 4s� neoc:Me ParenM Oivy) �
FesNence of r.nTer (it Oeceased. 6o s3:e) �
etruip�ace ol moaer (Saa or loreipn cwnq)
I acknov.leEge ihat I have
�hat are sezualy varemine
immune deticiency syntlror
@tgnaWre ot Applicant —
i
fi. (a�FWlremeofeppGOnCSlat�er �
(11 aaop;eE, Iis1 Atloowa Parens ony) —
Resitlence ol h;�er ('d Oecease0, so sta:e) �/
BiMplare oi faNar (SWte oi loreign cour.:ryy.
(bIFM �qen name al apoOCanYS mo:tie��'
(II aEoO��. �1 baptive Paten50Ny)
Resbence ol mo;�e� (�t EeceaseE, w sa�) �
Bihlplace oi moNer (Siate or foregn ra�ntry)
v
ACKNOWLEDGMENT
ommuniwble diseases I acivwwletlge that I have receiveE intorma:ion regartling tlangerow wmmuevcabte diseases
causes AIDS (acQUired �hat are sexually t2n5m antl a lis of II+ test 'tes fo ihe virus �hat caus¢s DS l�cpwetl
�1 / .� immune Ceficienry ts'yn �t � �
Date � 'S� �'rnature ot Apdicy✓ Date
The above applicant has ebjectetl to ven:ying by oath or aHvma:ion or sigr¢tura to ihe above The above app6cant has oEjxted to verit}ing by oath w atlirmation ar signa:uee m the a�ove
acknowletlgmen; because ol reG/gio�us �e6et5. aclvwvAetlgment because ot religbus belie:s.
Ge�kolCqW / 1 �_ Da;a GerkalCourt DaL=
SIatB ol 1`tlana
Gounry of_
SuESCnbeC erd swwn �o
ine inlorma W n piven
ol ine Gibson CircWt Court
CONSENT OF PARENTS, PAqENT, OR GUAFDIAN
We, Ne paren5 of ttds app6canL here0y g'ne menem for tnis mamage. II oNy one parent sym.
stata lacts w�ich nake ihe consent ol t�e oNer Darent unneressary
State ot Irdmw �
Counnol 1 zs.
MoNer
SubsuiEeE a`b sxom to before me Vtis
Aay ol
ID �
ID �
Glerk
Sta;e ol Ir�C2na � I svear/alivm Nat Oie vdomation given
Counryol �- / ss- initrLsappf�t�" eWeanEwnsc
�� OI70(��zK�, �lY /!/,!J
Ne� FCCress —
Subsvibed =M svom= Oel�re me uiis daYOl .�a�
� n. �
oi Ne Gason Cvcuil Coutl
CONSENT OF PARENTS. PARENT, OR GUAR�IAN
We, Ne parents d th's apptipnt, hereby ghe w�5em Iw rtus marziage. Ii oNy o� oarent sgns,
sa:e tacts whk� make �he wnsent ol Ne cNe� oarenl unnecesury
Sa;e ol IeMqw �
Couny ol �
SWSCnbed aM svpen b belore me Nis
�
io. _
io � _
eay o�
Clerk
COMPLETE IF MARRIAGE LICENSE ISSUED BV 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 direcis the issuance of a marriage license to the above named parties.
RETURN OF DiARR1AGE LICENSE AND �tARR1AGE CERTIFICATE
f certiJ}• that there wns filed in my ofJ�ce m m�rringe license iss� ed b� r e Clerk a he Circuit Court Q/ Gibson Counht lndinna.
dn(ed�l� i d�3 . nathRri�ing the mnrriage aj_A��'I� — . and
l fi�r er cerr�f� tl t Jq; %ollowi�ng ��n� n.nge certifirnte tvns filed iii irii� offic � �/% �Q� %�
l. �%'�-�/ (i� me). c%.rtifi• �hat i� (dnte�l,. ats�B4�'✓`� �� in
, Q'►� Counry. h�diann�._�1�L�[iY�ji����� �,Q-v�s�—oj�'Y� Counn•.
(stnte). and-���'�`� - af�.�say-- Co�uuy.
�(stnte) were married by nte ns nutltori�ed under a ntarriage license that �vas issued by� rhe C(erk of the
Circuit Cour�oJ�G,,i�6�son C���n G�� ln��lim�m., �dnte.d ��� �'D'n 3 ,
Sigried by:G�� �"��v� . ��t--�(po�"'ci-n( d`e/signatian)
Filed nnd recorded in nctordaiue �ridi the Imvs of the Stnte oPubdinna on �s �� 3(dnteJ "�
Signed �' Q,� �_. S- I..��....,,�,jCBn Clerk
�
Gibsoi� Circuit Coivt