Marriage Certificate - Hiatt, Sharla K_5/13/2005.
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ICJ7-7-8-1. FumlthlnqfalsalntormatlonuponepPlylnqlorlleense.
A person who knowingly furnishes false information to a clerk oi the
circuit court when Ihe person aDGlies lor a marriage license under IC
31J-3 commita e Clene D lelony. �
STATE OFINDIANA• '
APPLICATION FOR MARRIAGE LICENSE
GIBSON COUNTY
H.m.
MALE APPLICANT
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' �LKNOwLEDGMENT
1 K�110�kEJ0It1�1 I Nvp !KlnM �niormaiion reqaravy aanqerws wmmuniuda a�uaaea
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No.
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De[e ot AD lic tion
Female Applicant 50 > No Yes ❑ I, I
If No, Medical Exemi ion r eted ��
Neme ot Physician
Hama
FEMALE AOPLICANT •
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t. 1re you ro� a ���x you Mr Eeen �U"ryOqeC to M ol unfwM mi'q? NO Ye ❑
II �ns�er 4"YH: �u ��e �El��tion Eeen removeE? No ❑ /Yp ❑
t. �re you rolafv0 a Ne maN �pp�iunt cbur tlun wcoM mwNl NO ��/ /�'y�
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Rnber¢e ol motner �il Ueceaae0. w atete) _
Bitlnppro ol mol�m �Sple o� breyn cwnlry)
•LKNOWLEOGMENT
1 ackrpwleCge Wt I �eve reCeivaO infortn�tion regarEirp Oanperoua cpnmunit�de Eife�fef
inatareuawnytnmminea.ena�iis�oimu1esuitmrorineriru�tM�uuu� Sdcauirea
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G�n M Caln Da�e Cier� o� Coun Date
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Counry oi Gipon r/ `\-'�`V" ���u� �odvatbn n vue a�a carec�-
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Gipson Circult Court
CONSENT Oi GAqENTS. GI�FENT, OR GU�ROIFN "
WL 1M W renb ol t�is �pd�nt. �sr�OY O�re cMMnl lor t�ia mlrri�9e.11 onlY �e W renl fgnf.
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GONSENi OF P1qENT5. V1qENT, OR GU�RDInN
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euie lana .nbn mawe �ne conunt o� me omer wrent ennxesvry
Suuonnaum �
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F�U�er 10 •
Molner 10 •
SuDUriME aM f+�om lo Cvlora me tnis - a�y o�
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COMPLETE IF MARRIAGE LICENSE ISSUED BY OHDER OF COURT. A marriege license naving Deen reluseC to the above name0 parties. Ine
Coun�y CAUrt, by written orCer iuueC
enA IileC in authorizes and Eirects t�e issuance ol a marriage license to the above nameE parties.
RETURN OF MARRIAGE LICENSE AND MARRIAGE CERTIFICATE
I certify that there was filed in my office e mamage license iasued by the Clerk of the Circuit Court of Gibson County, lndiena,
?� dated � f y 5 authonzing the mamageqof and
.�, �]�-���`-`�-�--�-•� �
I f er cer ' y that [he following ryarriage certificate was filed in my offire: •
I, __ �`P��P4-� (na e), certify he[ on � f 9 (date), a in
County, lndiana,/ �� of County,
(atate), and r9 x. � ot County,
�� (atate) wem married by e ea authonzed under a marriage license that wes issued 6y lhe Clerk of the
Circvit Court af,Gibson�ounty, Indf�na, dated � % S .
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Signed 6y: �� %7w� y�f� , (official t+esignatlon)
FSled end recorded in acrord�iire with the lawa oI the S[ate ot Indiana on
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