Marriage Certificate - Holder, Chastity_6/3/1998ram n..sne.a e�
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STATE OF INDIANA
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APPLICATION FOR MARRIAGE LICENSE
GIBSON
ICJ7-7•&1. Fumlthlnylelielnlormationuponapplyingtorlicenae.
A person who knowingly turnishes false inlormation to a clerk of the
circui� tourt w�en ihe person applies for a marriage license under IC
31•7-3 tommits e Class D telony. �
MALE
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�GKNOWLEDGMENT
I�ckMnlp9� IN� 1 Nv� rtteire0lnlwrt4tron requ0inq Ua�erme cOmmunka0le E9eafel
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CONSENT OG >.ViENTS. P�RENT, OR GU�RDI�N
we. IM wnnb ollftif �odk�nl. I�ereEy pire consenl lar Inn marrwye.11 onry one o+renl aqns.
tbY bcta �lYC11 m��� �p� �pnflnt ol Yy pNN W�enl unnCteiiiry
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No.
File
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C O U N TY Date ot Application�
Female Applicant 50 Tt�tp ❑ Yes ❑ • ('
II No. MeAical Exa ination r Report Da(ed a_ S- S b
Name ot PhySiGian �
FEMALE APPLICANT
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•LKNOWLEOGMENT � �
I acYnowleEge Inal l Mve rKeireE inlwmation regardi�g Eanyerom cwnmu�da Ui»aMa �
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Counry ol GlDfan I�
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New AEEress r1
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in I�ia �Od�f2lion i3 We �M m�p[I.
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a tna GiWm Circuit WM
CONSENi OF PAqENTS. P�RENT, OP GU�ROIPN /
We. ��e pannts ol t�is �OWkam. �aeCY Sire consent Iw Nu martu9e.11 oNy orc yrmt igm.
sUle lacb w�K� nvYa 1M COnftnl ol t�e o�ner W Rnl uMttnvry
$YIeOIIMiJn� � � �
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P,mer �o.
Mol�er 10 •
Supfcrippp �nU fwprn lo Eelae me �nit _ yY ol 19_
Gerk
COMPLETE IF MARqIAGE LICENSE ISSUED BY ORDER OF COURT. A marriage license having been reluseE to Ne above named parties. t�e
Counry Court, �y writlen or0er issued
8^4 ���� �� authorizes and Airects I�e issuance ol a marriage license to Ihe above nameE parties.
RETURN OF MARRIAGE LICENSE AND MARRIAGE CERTIFICATE , i
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f certi y thet there waa filed in my office a merriage license issued 6y the Clerk oJ ehe Circuit -Court of Gi,6�san County, Indiane,
da4st�6d�L'^ J-4-i�, authonzing the marriaee of �- � � L�' ",��� ��-C..K('� and .
//
IfyJLhe certify at the f rn.ing�mamage certificate was filed ir{�my o� e:Q
I,%"`- a� `?. f�"" -� (nai e).•certif that on �1[Q- e7 / / Y S�!
Y —� (date), at �q,_ in
YJtA�e�v CountY, lndiana. + �• f���. � of �
` � !, � � County,
(state), end of �U�v>a.e.N County,
�p%`— (state) were married y e as eut onzed under e marria license thet was issued 6y the Clerk of the
Circuit Cour Gi6s Count. nd' a, dattd 9Y
Signed 6y: � �.�R . (oJficial designation)r/
F71ed and recorded in attrordance with the laws of the State ot Indiana on l t�(de��.
............_..,... Signed ��'^-i 2 �I���� Clerk
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