Marriage Certificate - Deckard, Jeannine S_1/9/2012f �
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STATE OF INDIANA
APPLICATION FOR MARRIAGE LICENSE
GIBS
IC 31 • 7- 9- 1. Fumishing false information upon applying for license.
� A person who knowingly furnishes false information to a clerk of the
circuit court when the person �aDPlies for a marriage license under IC
31 - 7- 3 commits a Class D felony.
APPLICANT '
NdmO / � /� / �f��0 �� �� K ds�. I /
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Dale W BiM MoM� �
abcedew+lA aeqnw.aM
R�/��Li4.[twl.> ���
predpa My1al $tat�s: Nwa MarteE ❑ OR No. W Ravnss Marnages �
Lasl Martia9e EnOM BY DeaN �i.vrce ❑ Mnutrneti 0 �ale
Date W GM �ei6rL Ey ❑ Bvin CeNfrate m(Spetity)
1. Pre yau eM ot I+aw you eve �em x0�W9� lo Ee ol �hSauM mvi0? No� Ya ❑
II ae¢ver ¢ Y6' Iws Ihe aEjWit�a�p� Oeen removeE7 No ❑ Yps ❑
]. Ne Ya+relalM b Na lemab aDP�N rlostt W n semH co��? No Yes ❑
7. Na yw row uMer Ne inlluence ol an akotidi[ �nerage? No 1'es o
� a. rve �ou now uMe� Ine cJ4ence d a �aiwtic aNg? NO Yg O
m
5. LLF Ine hA �ames d airy aepatleN W1Erm.
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2
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(a) F�A �ame of app5wN's taNer
(Ii aCro��. W POOqn'e ParpY�
0.esiEarce o1laVier p aecraseC. so sta�e) —
BYt�td[B D� idI11C �$IdIB 0f �IXlI�11 NI`/) -
(p�td (NbCll f�BtM 0� dpp6CdN 51110:�2!
(II eGOD�eO. ht AOOM^'e Pamn�s O^M)
RevOerce ol mal�er (d OecvasW. ao sfate) _
Binnptace o/ moRier (51nm or faegn couMry)
ACKNOWLEDGMENT
I atlrowledBe Nal I Ifave receivetl NOrt`u�im rM�drE� Oazgn urvcaWa Cueaso3
Ihatarasezuallytrznsmine0. rM 'alolNetasisit 1 Vqd icausesAlD (acq'e0
irtmuna0e6tlenrysyMr y�� �� Q
SgraNraolApp5faN . Date
File
ON COUNTY -02 � O
ate of A lication
Female Appticant 50 > No O Yes ❑
lf No, Medical Examination or Report Dated
Name of Physician
FEMALE APPLICANT
Namo
Date d Biln v MoN� ar
Place af � n c• te a breign m�nuY)
R� SU wRR Giry n �
Prevpis AWNaI Sfat�¢: Never MamM ❑ OR No. of Pre��iws Mamages �—
lasl Mamaqe E� By DeaN O �wpceX MmWKN ❑ �s
oate d evu+.erae� oy. o Bvtn Genifcaze � Otner (SV 1
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327
l. Ne )OU fOr IX INVe yDU CM DBCI13EpIGal�1 b OB O( uM150uM mYlOi P10� Y!S O
Ii a�wv s'yes.'tws I�e �jWimtion Eeen remov�? No O Yes O
2. Are Ya rehi¢0 W Iha male xDO�caN cbstt Nan semM musn7 No � Yez O
]. nre )au Io.� uMer tire influerce of an atoro�c Eave2ge7 No,L va O
a. pre you now uMn me nlluerce W a�wmk aNg1 ��6L Yes ❑
\
5. LN IM tu1 rames ol anY OepeMeN WNm.
6 �a) F�C �wne d aoo�M's fauc
(11 aEapteC. %� MoDlrve PareNS OM/I
Raamce N hurer (J eseazea. w saze) N
B'vNdarc W �alhtt (SUte w Iweign munuy) —
(O��ID maOm reme ol appFZN'a nulM
N aGUWeC. W Mo WK Parm6 Q�N)
R6Gerce d mWfer (U Ox'asvA so siate)
BiMplace ol mpU�tt �Slale w b2ign cwNiy) -
ACKNOWIEDGMENT
I afkrorleEge W� 1 tave eeiveE iNOrtnatian reparEl^D EaMarous mmmurvpWe Eseas[
Itwl are snxua0y Cansmi . a�a a fsi ol l�a tesl sitBS b/ Ne �v�f Nat mu5vs AIDS (2W�
immwxaefitlen�ysyMr �' r•J
$ipnaNre ot ApWk2N �lO�7 a
T�e aEwa appl�nt Ms aD�OqBG to vaNyv�p �Y �N m affumaUOn w signatwa to Ne aDOVB Tha acova applig(u tias oCjeaeE to verlly'ug oy oaN w af&maxn or sipwWre b Me aEm
ackro�MeOgmeM Oaceuse ol re6gbus Oeliefs. ackm�NeOgment oxausa of re6gious De6e[s.
a�aw�n Da�e perkatCw� Date
Swa d Wiara 1 I awrarhdffirm Rai Ne inlartaton given
�Y a � ss. s appfcatun' we aM mrted.
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Sw� aMSwmWEeldemeVrs��EaYd�.�di
.h�..//. /,l__ , > c�oiUac��w,a�,aca,n
CONSEM OF iURENTS. PPREN7.OR GUARDVw
we. ine oarmss o( N's apo4aK �arDY 9^e ��^� ip Vus martiage. II my one oa�w sgr�s.
s�d1013q5 w't11Ct1 rtNk0l11e fDrtTCN ol lt�< ONtt pdtMl uMKlSidry
Sute of InOUre 1
CouMyol I ss.
F�y IDO _
WNa IDS _
SuRwiOeE anE 5wom lo Defore me Vis —�Y a .—
Clpk
Sta�e M IMUra ) I sv.eaz/afFum Rat iM'v�ion 9nm
County W i a. n Nu a0v6u�iu+k uue ero cortv�.
Sg /f�Y//,�1� L1_J 9 J �-�--? -
New
SuOSoCEea ara swm to Oebre me �4°Y �I�'�' �--�a�QC �i
m u,e c.mo� cm,n co
CONSENT PAREMS. PMEN7.OR GUARDNN
WR Vie 7arems ol Nis aPM�nt �xeg' Biva ransenl for tM martiaBe. 11 u^N we Da� s9�
atate (acLt wtuli make V�e wnteM ol Ne d�n parenl u�ufttessary
Swe W Wiana 1
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Fau+er m� —
�i�� ro e _
SuosaiDaO aM swm m oeW e me ufs _ EaY of .
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COMPLETE IF MARRIAGE LICENSE ISSUED BY�ORDER OF COURT�Ya'martiage license having been refused to lhe above named paNes, tf
County � Court, by written order issued
and filed in , authorizes and directs the issuance of a marriage license to the above named parties.
L/ cerr f/i�
��' datedl�
RETURIV'OF b1'ARRIACE LICENSE Ai\TD'�11iCRRIAGE CERTIFICATE
them N�as filed in n�r o�ce a rnnrrrage license issued hr rhe Clerk of the Cirr Courr J Gi6son Counnt lndian
w oZi,�iOO � authorizjn� the marriage oj�./�-r.d��� e�C� ana
/ ur � er cer ' tha! th ol wing mani ;e cerrificate H�as filed in niv o�c '
If � (name�, celtijr thur on � �'ad�(date, at , �
Counnt /ndiano. oj Coeenrv.
(state). and • of Counrv
�(state) N�ere n arried bv me as authorized under a marriage license that was issued bv the Clerk of the
Circuir Courynf Gi on Coi � �ana, da d Q �
Signed bi�: �� —�L 1�� rti� °��ci I designation)
Filed and recarded in ace•ordance H�ith the lax�s ojthe State of lndianu on i �� (date).
, Signed �L4�Cle
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