Marriage Certificate - George, Dana R_5/30/2008�b-�q-i�-3o3-00o ab�oa�
STATE OF INDIANA�
APPLICATIO O
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N F R MARRIA LICENSE
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IC 31 • 7- 9- 1. Fumishing talse IMormaUon upon applying tor Ilcense.
A person who knowingly furnishes talse informalion to a clerk of the
circuit court when the person applies lor a marriage license under IC
37 - 7- 3 commits a Class D felony.
Name F4s� ' Aab I'1 . Las /J
^.G � � S�L. W .C�
.V/
Dala oi BvN
Place o� B' tale or brapn countryl
�EE( SV�sIaAR CCy nry Sdb
Pievpus Marrtal StaWS: Neva� MartwC OR No. ol Fev rtieqes
ltst Martm9e EMSE BY: 0.am ❑ Oivace ❑ Amuin�n ❑ DaN
Da�e ol EvN wNqC(b�y. ❑ B4N CerCMSte ❑ Omer �Spac%�
—�/� L � C.�t . O . - l �
1. Ara yau mw or t�ave you ewr Dean eEpqpeE b pa ol �nsouM mvtl? No � Vps p
11 e�wr'a yes: tus �+e aCj�tliratqn Dsan remove0i No C✓Yes ❑
2. Are you ��pbE b tli! lsrtmb appfvn� cbset tlmn seCOM m�rsin? NO fy`� Yes ❑
3. Ne yau row uMe� Me'uJLence ol u� etoMlk peverage'+ No Y Yes ❑
�. � Are you nvw �rtMee tM inMnca d a narmac tleuq? No�vn ❑
s. uv me iw ��: w a�r �w�m wn�e�.
(a) F� wms d ap0��r� harer
p� aEOO�sa. h� atlooWe Par.nn OnN)
RetiOan[e of lather (� �seC, su sqle)
BiNiphca ol hetMr (51ab w laeiqn cwnoy)
(0)FN maqan narre ol eppNCanfs moTe '
(11 aOOpiN. fst pdoptivs Paren¢ONyI
ReaEence ol motner (II CxeeseE. so ptsl
&rNp6u o� rtqumr (Sab or laeyn country) �
ACKNOWLEDGMENT
I ackroMedge Riat 1 have receivetl " rmalron reg dieg tlangero mmur
rtiat are sex�aly Iraremne of N lesl s fa N et puses
immme EeYiency s e
'1( Sipruwee of Applin ie '
The a0we apd�1 haz oEjxteO �o veril)v�g Oy oalh or
xMroxletlgmmt Oecaise ol yd5� �titls.
Cbrk ot Cwl -
539
No.
File
�DN (:VUNTY ,C�������
Date of A lication
Female Applicant 50 > No ❑ Yes ❑
If No, Medical Examination or Report Dated
Name of Physician
FEMALE APPLICANT
Name
o�ie a aw,
Pmvious hlariqlStlEn:� Nevae Mareis0 O OF No, ol Previom Mar(eges ��
llsl Martiape EMaG By. DeaN ❑ Uwrcl� AmNmenl ❑ Oab d
Da�e o� biM vantioG py: ❑&M Cemliceta ❑ OUror (Specily)
(��-' /L i . . J C�C3. _ ' °
Q
2.
3.
a.
s.
Are you rox w luve you ever peen aCrytlgeC b G ol umounE muq?
If answar rs Yes: Iros Np aCjWici40n Dean remOVeE?
Ara yJU ralaleC to Vb rrele applicenl Cbsat itun EKO�M �'nuam?
Nra yvu non unCer Ine inlluarce ol en akoMle Davarage?
Are yw now unEer Vie influerce oi a'urcoLC Orup?
lat tne lul4r9nes ol eny aepenesm Wc ��
6. (a) FNI fuma ol appl[anCS hR�er n �• _ ��
ResOSnu ol fatlrr (il tleceeseC. so statp) fe
BvVWlace oi faNSr (Spte w b�aipn country�!
10)Fu0mai0ennameolappGranYSrtqtlrr �
(Ii aEOpfeO, fai AOOpYVe PannS pJy)�,
ResEence ol motlwr (il CeceesaE. w sfab) _
BiMplece ol rtn�ner (S�ale oe lorepn country)
No (�/ Yes ❑
No � Yx G
No � Yes ❑
No � Yos �
NoC� Yn ❑
ACKNOVlLEDGMENT
tliseases I acknovAedge Riat I liave receiveE iNO�mation regardirg tlangerous wmmunirable diseases
aW J� ued ihat are seaually Uararttitled, 6 t ol ihe ta f sne, tor� eyv�qthat�ys a AIDS (acQU'v/edy�
, /� � immu�re Oe:ciervy �rane) II 1 �1µ / [I �21 _��(-
���P $�9�tureolApplicani y ���7{te ��
w sigreWre to t�e above I The above applicaN has objecteC to venM^9 �' �N or attitmali0n or sign3:ure �o Ne a0ove
acknoWedgmont Eerausa ol re5gious Cetieh.
Dab � Cleeko�Coun Da�e
Sp4 0l InOwn 1 I svnarh:frm Wt Ine nlormation Qivsn
Gounry ol,Qa.+�!�«'—' 1 in u�s �DACation' e aM wrtatt
� �B
NewAEtl�scs �[�
SuDZCriEeE aM vv.wn b Dalp1n me ail�%�(�jay o1 ��
/1 �.. • n� 1.i� ' �Cbrk oi iM Gipson CircWl Gouet
CONSENT OF PARENTS. PAqENT, R GUARDIAN
Wa. Vw {erenS ol tlfrs dppf�nt. �ere0y pive Consenl lor tivs martvp0. II onty ane paeant siq'K,
stale bc4 whk0 make 1�1 COnsent ol Na oPet Daron� erviacassary
SquollMUm �
GOUNyaI ) 55.
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SubscrdeC aM cwom b bebe� me Itis — CaY o� ,_
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Stata W IMmm � I cxea�lef4rm Wt tM nbmuiion given
Counb ol ss. � in aDDM1�oo '' vue eM mrtect.
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CONSENT OF PARENTS. PARENT,`bF GUAqDIAN
We. Vre pe�an6 0l Nit applicant fre�eCy 9rve caeenl b� Nrs martiape. Ii oNy ore paren� sgns.
s�aie IacLS wnic� make �ne cqnsent ol t�a olner paran� unnecessery
Slale 01IrMiene �
COIIl1�`/ OI � 55.
Fatlror ID � _
Mo�Mr ID � _
$IICWI�ltldMSwOlnbCGlotelf�B:tlb�Ody01 ,
GIeM1
COMPLETE IF MARRIAGE LJCENSE ISSUED BY ORDEq OF COURT. A marriage license having been refused to the above named parties, the
Couniy Court, by written order issued
and filed in , authorizes and directs the issuance of a marriage license to ihe above named panies.
RETUIL\ OF il1ARRIACE LICE\'SE AND MARRIAGE CERTIFICATE
1 certifi� t at rh e x�as filed in my o�ce a marriage lirense iss�uerd b� the Clerk ojthe Circuit LCourr ojGibson CounRt lndiana,
dor�d ' n� OO ,auhorizinJJthe�narriageoj G, '��-��i�J L/�,�{��; �C� and
A / �- -
lju+lher cerdiv�the,{oljqwing maniage cer�ificate was filed in mv
� �'� �r .r
1.. n- • y •�-�-+,�--�+^- (}q ). c
��o `�nCounN.lndiana, G
��nx-_ (smte), and
ea���1 (smteJ were married by/me -as
Circuit Coucl.AfGib'sOn Covnrt�.lndtLna. dated�t
Signed 6y: �� �"'"� /T �J
Filed and recorded in accordance with
���,� ,T..
under d maniage license that x�as issued bv rhe ClerA ojthe
-� �. i
Gihson Circuil
in
Clerk