Marriage Certificate - Dill, Jan E_2/13/2001634
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STATE OFINDIANA No. —
APPLICATION FOR MARRIAGE LICENSE F��a
GIBSON
IC 37-7-&1. �FUmi�hing falte Inlormetion upon applying lor Iicenae.
A person wAO knowingly furriis�es talse information to a clerk ol the
circuit court when the person applies tor a marriage license under IC
31-7-3 commits a Class D felony. .
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- Date ot Ap0lication
Female Applicant 50> No ❑ Yes ❑
If No, Metlical Examina'on o/r�Re ort Dated
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CONSENT OF FAqENTS, PAPENT, 09 GU�FOJN
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CNrt CIM
COMPLETE IF MAPRIAGE'LICENSE ISSUED BY OROER OF COURT. A marriage license having Eeen retuseE to t�e above named Darties, t�e
Counry Court, Dy written orEer issue0
ana lilea in authorizes artl Eirects Ne issuance ot a marriage license ro IDe a0ove nameG panies.
RETGRN OF r1ARRIAGE LICE�'SE AtiD MARRIAGE CERTIFICATE
1 certity that there was filed in my office a mamege licenae issu.e�d /6Jy tqhe� C�lerk of �the Cnucuit Court of Ci6son County, Indiene,
dated 1�! ���1 yrL, aothorizing the marriage of /�!� �� and
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I iher rertj�fy that follou�ing marnage mrmhtate was filed in my of5ca' '
I,�i�t.u�l.%li� (neme) re itY �et an y/ y` y (datel, at in
;d+�� Counfy, lndtana, of County,
(state), end of ,/�«�� Counfy,
(state) c�ere memed 6y me es euthorized under a merriage lirense thet was issued 6y the CIer4 af the
Circuit Cour[ f Gi6so Caunty, d�ane, dated �—� �� y r1 Y .
Signed 6y: (�y�_ • �'L'� "" ^-' , �—��M++� (otficial designaoon)
Filed and rerorded in accordanre with the law's of the Stare of Indiena on 1 (dete).
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