Marriage Certificate - Esarey, Cindy_3/29/2001r«�+r�«��e«m STA7E OF INDIANA No.
IMtu�� Sltb Bura N
"'�"�'°"""°'""" APPLI�ION FOR MARRIAGE LICENSE �File
a���,-r�
GIBSON COUNTY � a
- Date of Applicati n
IC31•7-9-1. Fumlfhinglelselnlormetlonuponapplyinglorlicenae. FemaleApplicant50>NO ❑ Yes ❑
Apersonwhoknowinglyfurnishesfalseinformationtoaclerko(the IfNO.MedicalExamin3�(�norReport ate_ �'�
circuit court when ihe person apDlies for a marriage license under IC
37-7-3 commits a Class D felony. Name ot Physician /it �'iti���
MALE APGUCANT
D�te ol Binn
RK! W BiN
>�eriqn MentelSVlua', Never MLrieO O OR No. of Prmiom
Lasl Name � Firs�
Yee� Dafe ol Birtli
Placeol9i St I loreign
/ Reaia/ / 1 `J ��—
i0ee Fmvi usMental5taws: Nere
/
WtMUmpsEnOWBy: Dea�n C Divo¢� � �nnvlmmt Q Date
��noloirtnrarlfeaeY: ❑BiMCenil�VU m ISqec�yl
L �reY�nowOrMwYd+� n� toeealunfourWminaP NN� vpG
1� �ns�e� if'yes: �af Ne aCNd�����a� �een rtmOVCO? NO rJ Yef C
'1. �f�yWI�I��OC�pVIQIlT�Ip�pplK/f11CIOfTV1�t1�lCpbCWf�lli NO���/yYlfL''
J. Meyounowvnartmein�Nmceol�nakanolicDevmqe+ Noy Yee❑
�. .�llYpYllOwVn00ltt1lin11U0nClQI�nBlCO�i[ONq? NO�YHt1.
i i mewllmm i�nYaexnaa niifren.
.' �/LI�R�J�/YYi . . C
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6. (e) WII Nme ol �p0lic+n(f bt�er q� p
n�.aoo��.�„�.aa��..o„��„o�n��ltYQ eAdtOn(�5�
Reeiaence ol irtner 1�1 axenea. so na�el
BIn�O���e ol IaRer (St+;e w loreign rouniry)
�e�F�IIm�iGmmmaofaoe�c+mYmotner ��_1Q�,.�yM�,
pf �000iM.lin �aoJU.e oercnu ONYI G�� -,��I�kSNL
Resiaence ol motner �il aecdfea, so fuie�
BinnD�ae o� motna (S�tle or imeign coumry�
�CKNOWLEOGMENT
I actno+ieEpe ���1 I Mre rxeiveE Information reqarEinq Uanperous communicaCle Gseaus
�lNtil�NaYlllylldf.fTiI1M.�I1C . 101�1f[�f3�]1:t)IOI�i�u51N�ICd�J]lfAIDSI�COUi�Cp
immune aetinen<y synarome�. ���7�q'�
Spiuroreouoo��unt Date �<��L�
ine axn aooi�um r.as jecttE m renfyin9 py oam or aPormation or sign�mrc to me aeove
¢�nawinqment eeume a� rtiigioue eebe�e.
eknolCOUrt oa�e ',
Sa:eo11n0iens � is.earhtliem�nnme'mbem��iongiven
CounryoiGiOaon =�0 int�isa olicatianistmeer.acarren. '
SiqneC� �
NGw �OE�Cf
Sueacr,eea am �+om,m xtoro me mis � aav ot t9
Na Giown Circuit Coun
CONSENT OF P�REN15. P�RENT, OR GUAROI�N
We. Ne oumb ol tnif aDG���t �moy gi�e <anuGl lor P.ip mertuBe.11 onN one oarent fiqns..
St��! I�CI> wll�iC11 mdka 1�! COn3lnl OI �11! 0111lI OdlGI1� unnKG33lry
SUteolln0ian� )
Countro� � u:
FaIDer ID •
Mol�er 1� •
SuOrznpeC ana swom ro Detort me ini� _ aay ol 19_
CIlrt
FEMALE APPLICANT
ieE C OR No. ol Ptpviouf Martia9es � _.
LasiMarriapeEnOeEBy: Deatn❑ Orvwcey� �nnulmem❑ Date �y�,
f'
mce m o�nn..n:;ec oy: ❑ eirtn cemroi. �OIDer (Specity�
��. �' w�/ � �
1. Rre yw r.ow or �ave yw ero� �een sejuEgea to Ee ot umwnc minCi N � Yn ❑
II answe� is }H.' �af t�e aEjuGicstiOn Deen remowG? ND O a O
2. �l! yOV flIG:M I0111� TGIClOPIICLl1� CIOY! [�Ip11 fKOfIE COYfY1? //Yb �
J. nre you now vnEer �ne Iniluence ot an alconalic Deverege? NaK/ /'/�p �
a. �re yw now unaer t�e in:Nence af a mrcotic Erug7 ' No.C� Ye �
5. list Ne NII eames of any aepenaenl Cnibren.
6. �a� Full nama ol ao0�iunlb fat�er
pf aaoo�w, i�at �oaof.a varer.0 On ,_
RefiOence011a��er�i�UtteaxW,�ostall) —
9itlnplace ol la:ner (State or foreipn couniry)
�p) Full meiCen neme oi eOG�icaNS mo��er (�
(II dCOpteG. liel AaoO«+2 Farenb Onfy� y�`�
Aeaiaence ot mmner f� axeaeea. so sbiel —
Blmp�ace af mmner �Sbte or :omign wun:ry)
ALKNOWLEDGMENT �
I aCtnowleEpe IM� I pave receiveU inio�mation re0araing canqeroua communiuCle Cis�..--
mn m smwuy ttan�ninea, ar,e a us: m tne tnt sites ror me virue mat wmo MDS (aceuirea
immune aNiciency �yn ome/lq' P l�
Sigm:urealAOOliunt��` Vmf�M ^ ei /� � U d
Tne aDOVe eOD�icanl �af aEjttteO b verilying Oy oatn o� W.irm on or SlgnaNre io Ine aEOVe
azFno��ecgmenl pecause ol religious Eeliela.
Gefi 01 Cqurt Oate
SteteatlnElene 1 �: ��wearlatlmmmanneinbrma�iongiven
COUnry of GlDSan 1 in inis a00/�'f�e+M n true an0 rortttt.
SigneC
m
!� V�e GiMOn Ci¢uit Court
CONSENT OF P�qENTS, PARENT, OR GUARDINN
We. ��e pafenB ollpis applKar.t, f.ere�y L��e conaen; lor lnis marnage.11 only one.vrent spna,
s1aID lacif wnkn make ine consent ol �ne ot�er parenl unnecessary
SlaleollnEiar.a �
CoumY ol � ss�.
Famer ID •
Mot�er ID r
SuDMnCeO �na aMOm �o Delort me 6ia _ Eay 01 19—
Gbn
COMiLETE IF MARRIAGE UCENSE ISSUED BY ORDER OF COURT. A marriaga license having Deen refusetl to the above name0 parties, [he
Caunty Court, by wriven ortler issued
anC IileO in authorizes anC Cirects t�e issuance ol a marriage license ro the abo�e namea Darties.
RETURN OF MARRIAGE LICENSE AYD MARRIAGE CERTIFICATE
1 certify that there was filed in my office a marnage license issued 6 lhe C1erk of the Circuit Courl ot Gi6son County, Indiana,
dated -?� y y , eutho��g e mamage ot � �• � and
( fu er =' y th the follo 'ng amage cerlificate w s Sled in my of ce: �// n '
/ (nam certify that on . y (da[e), a[ ..�".�h� in
County, Indiena, of Countr;
�-��^ (s[ate), end of Caunty;
� n(state) were married v me as auth nzed under a marria license that was issued 6y the Clerk of [he
Ltrcuit Courty�G' sq_n CAVnty, In ' a, dated � .
Signed by: ��A f' (�� (o�fficial pdesignation)
Filed end recorded in accordance with t6e laws of the Stete of Indiana on _�]Sd��_J, �� 9 7 (date).
Signed
A£ML A/PO 1 R/10/59
Gibson Circuit Court
Clerk
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