Marriage Certificate - Harris, Cheryl_9/19/2002102 � '
FamRmLMBy • Q1 � � � STATEOFINDIANA •� No.
Mw SCb Bmd tl
���'�°i' APPLICATION FOR MARRIAGE.LICENSE F�ie "a�'�
,
GIBSON COUNTY Dateo ApplicaUon
IC 31 - 7• 9- 1. FurNshing false Informatlon upon applying }or Ilcanse. � .
A person who knowingly furnlshes false Information to a clerk of ihe F0ff1210 AppliC2flt 50 > No ❑ Y0S ❑ .�- li /�/
If No, Medical Exami tpa ion or�fle ated �C-
circuit court when the person applies for a marrlage license under IC P
31 - 7- 3 commits a Class D felony. ;� Name of Physician ��_(,i .
Da�e al Bbih '
APPLICANT
��'� � /+ tasl Name
� V LuJ
l (IQ�Y ' Y� �
, .��n �@ _ _ /.. - Pes�
SNWS NevuMartbtl� OR No.
la4 Martupo EMaO BY Dmtli O Ohror'z A I MnWment
i �
Dab d OtrV� vul(1atl by. ❑ BIrN
1. MeyoumwwliawyvuBVerplen00�WpW�bEeol�nSOUnCMtb7
I� emwer Ls yas,-has ItiqeOjWhatlon Eeen remwa07 �
2 Are you ralaieE b Ne la(nxle appGrant cbsaz tlun cecanC mu5n9
3. lva you naw uMe Ne hiCiw,ze olpn akoho6c Eeveaqe7
� �. 'm. uda rtce hdherce of e,arm�t Mqt .
N
@ S. OI an' nl hi�BR
ul
FZ /
Z
a 8. (a) F�ID fume ol app4enfs IaNr
Q �II etlapW. Csi ACapBVe ParenLt QYy) _
� aesEerca ot mmv ry Oecease0. m sp1e)
BIrOpIXeollaWf�$Iabwlwe�W WImUY)
(E)Fvll neNan narne ol appfranl's mo
(II eJOPbC. 4U ACODWe ParaNS ON�')
Rasldence al motlier (Y EaceasoG. w slate)
BIrlM1placa o� moNar (Spb w Iorolpn munhy)
Yes ❑
No` ❑^ Yez ❑
Nopl Y¢s�
No ld Yes ❑
Nom� Yes❑
�1��
- ACKNOWLEDGMENT �
I xYnoxletlge Nat I Irove receivetl'q/ortrelbn regarding dangerous mmmuNnble diseues
Nal are senaP/ VarsmiLLetl, yW 'SI ol ihe I 9 sites lor �ha v4us Nat ia AIDS (acqu4ed
Mmune OelNercy sy � �
Sigruture ot App6wn � �.20' � `��
�
The above appG�a ItSs oqeaed to verilying hy oath w�atfumali�n or synanue w Ne atave
arJ�rowledgment berause ol reegrous DeGeLs. '
Ge�k al Cou`I Dale
� a� �b� 1 I swear/alfvm Wt Ne 4Jomwlbn ghen
CauNV ol �/ w.. , n tltls eP7lkaibn Is true aM corzect.
J � / 1
Ti1�^j
Ne GSwn CYCUit Cowl
CONSENT OF PAFiENTS, PAf7ENT, OR GUARDIAN '
wa. me pvents a tlda eppfcanl nereGy pHe cmua for uus mar�ga. Y oN� me pa�ani sigre.
s�a�e tacLS wNCh make Il�e consen� ol Na oNer paren� umacessary�
SlabollrtlLw )
u.
FaNm ID I _
��r ID / _
SiIDw�eC eM cwom m W bre ma Ihls _ day al ,
Gbek
fi4Ui Mort} � � � l���Oa� I Lj�^ � Year
Pravb��sAfarltalStlius: NaverAlyn'eE� OR No.olRevbvsMa(rlages
last Marrhpe EnEeC By. �eaN O Ofwrce O Amimont ❑ Oaie
Dab ol DkN vM11eG Ey: ❑�^ CcrWimte tlyr'�Specily�
IV�v,i�2�-�i� ,
t. Are ynu now w have yvu evm Eeen aejuEpae b Oe ol wssouM m4Mi N� Yes ❑
II arimer h yes; has tl�e eEpqtaWn bean removed7 � No Yu O
2. Na YW /ela�eJ lo Ne imle xppGCani cb5u Von SemM cacNi Yas ❑
3. Na you mw uMer tlu trduerca ol an akoho9c beve2pe7 No Yes ❑
1. rVa you row uMer W Wuenco ol e rorwbc Erupi N Yn ❑
5. LLsl Na IW eeme o en n0ent MMr
_� �.�
s. (e) F� r�ame al appOCmfz IaNer
�I aAOpl¢C. pst REOpWe Parenfs O
flesltlence of Ialtisr N aeceaseE. m c�atel _
Blrthqaca ol laV�w (Spb a faelgn m tyl .
- @IFUO malden rome al �app4anl'c mo
(II aCOp�eC. fis1 AAOpWe Parenp ONy
a�me� o� �u� tu m�a�a. �0 1_
BirNpace al moNer (Stab or brelgn cowb�
. ACKNOWLEDGMENT .
I acknowleEge lhal I hava raceWed Wormaiion regard�g danguous commwY�ada Giseases
ihat are sewa0y tr 't . anE a I'sl ai Ihe t s1 Itrs lor Ne v4us Ihat AIDS (zryWred ' .""
immunedeficiency �e) �: _2'`
Signal�ue ol AppGcaN ,+ � pale U �
TTe above aOW� � o�i�� b ��Y�+9 W��h or atNrtta�lon or slg(tawre lo Ne ahove
aclaawletlgmen� bwause ol rWgbus bellefs. .
Cle�k oi Cqurl Date
State ol IM'rsna �_ j) I snearhlfum Iha� Ihe Wamratlon qHen
Gounry al .�) as. in uds ecv�uon %we and wnat '
n /1 /'. /� !� 1., � � .
NewA0Ero55
Ne Cabson Cecvu Coun
CONSENT OF PAflENTS, PAFENT, OR GUARDIAA-�
YJe. Ne parenls al iM1's appimn� �eieEy gl+e cavsent lor Nts��n4i9e. 1� oNy one pazW spers.
sta�e lazts whkh make Ne consenl al Ne oNe� pamnl umecessary
State o14Mlana ) ..
Couny al ) s. -
FnNer ID 1
MaY�e� ID t. _
SuOwmeE aM snan b 0¢loie me Ws - day ol '_
Clerk .
COMPLETE IF MARRIAGE LICENSE ISSUED BY ORDER OF COURT. A marriage license having been refused to the above named panies, the
County Court, by writlen order issued
and filed in , authorizes and directs the issuance of a marriage license to the above named parties.
RETURN OF DIARRIAGE LICENSE AND MARRI�GE CERTIFICATE
1 certijy that_ there was ftled �in nty o�ce a nearriage license iss�I by�he Clejk of th�C�ircui� Court oj Gi6son Cowary, lndiana. '
i. -
1
was filed in nry
a
! (datel. at
(smte/. and of ��sc�1�. Coum
� �� (stnte) were mnrried 6y_me aud�arize to�der n nmrriage license that was issued 6y the Clerk oJd�e
Circuir Co fGibsoi� Counry, /ndiana, dated C ! �
Signed by: , , o�c�a! designation)
Filed aid recorded u� accordmice �vilh the la s of the State oj/ndinna on �����L (date). � _
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