Marriage Certificate - Ivy, Elizabeth A_1/26/2009Fpmq�pNCO�
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STATE OF INDIANA�
APPLICATION FO
GIBS
IC 31 - 7- 9- 1. Fumishing hke irMormatlon upon applying for ticense.
A person who knowingly furnishes lalse inlormation to a cicrk ol lhe
circuit court when Ihe person applies for a marriage license under IC
31 • 7- 3 commils a Class D lelony.
MALE
name �,f%'b_J n�L ie�._ci�Y'��
Uate d B'utn Mpnin� a� � llc��
ol
vbce d BiM ( a breipn counUY)
q�4�0� Sireet a C<Y Y�� /� �_ /�
� V V ��r�..•rF_
Prt�iaa MaLIStaM: Never Marr' OR No. al Roviws Martiaget
laa Martiage EMN By. DmN ❑ Diwme � PmW`wM O Dafe
Date o1 e'vtn �erbea bY ❑ BiM G' te a(SOedNI
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M�vu iww� a Im pu avw Oam xlj.bpeE b Os o1 vrtsaniC mM No g Yes O
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tl aronar s i'Q� Aas Ne aOhLKalion Deen rertqve07 No �❑[ Yes O
M yau n1slaC b Ne /mule appfiutt cbcer tMn semrq m�cini No� Yes p
M �w mw unOm Ne iil�erce ol an almlo4 pprerepel No Yes 0
M�wrowwGaNanfluereedaremd'sAnq7 No� V6❑
l"at IM hA romes o/ anv OeoenEeN WlEren
p) F�A �w�e d epqkaM'n hNm
(n WoNaa. �a Moplirn Parcw Or�ry')
R..eerc. a w,a (a aaeaua, w vmo) O�
6eUWhce W Su�r (Siaro a bregn muwY) d,C'
(O�W mei6m �urtro o1 aPV�ur�'s troNx
(I/ e0optsO, M ANptive Vanris ONy
ResiOmice ol nqNer (A CeceneG. so pxte)
BtV�pbce ol nouim (sbla r bre9^ �')
ACKNOWLEDGMEN7 �
�,wqw+aOw wi � n..e recar.a wormatin, rey..avg aznq«an mru`wrvfaaa 6seasu
Wt �n sexwP/ tnrtuntlo0. anO a I 1 �he t vist lor IM vuus WI fa�¢es ND (a ' ed
imm�ns OeStlmry s m e)
SiqneMedPyp6nN � Dat� � G 7
TM e0ow applfraM Ms o0jada0 W veNyvg Dy oaN ar aRrtmaUOn w sigeuWre lo Ihe aCava
awww+o0gmav oeo�se a religb�¢ oe6efs.
CbA of Cart Data
Slale d 6tliana 1 1 swoarlatlum Wt Ne iJwmalun given
GOUMy OI � ss. i� N6 aDG�uliOn 6 Uue ietl mrtlCL
Sig^eE ,/ `l./
NnvAptlrnS S^
$uUsaiq)ames.w„meemr.meuu � axya . '�"Ui
ofNeGmwn
CONSENT OF ARENTS. PARENT, OR GUARDIAN -
We. tM pam#s ol 11m appicanl, nerepy gire rrnspru Ipr Uis martvge. d Wy one pa�eN sym.
swe Ixis w�c� mate t�a rvnsaM of Ne oNer pamm unnecmury -
Slaleaf4tluna �
^_ . N— � ss.
�ama ID 0 _
M� ID a _
Su0w1EeO W swan b Oebre me Na _ CaY ol ,
Clerk
R MARRIA � LIC�NSE No.
File
oN couNn a-G_ o �
Date of A lication
Female Applicant 50 > No ❑ Yes ❑
If No, Medical Examination or Reporl Dated
Name of Physician'-� �
FEMALE
Oale o/ BtrN
Plxe al Bttt�� or breip� counpy)
Pre�naus
OR No. ol Previous Mareiagm
lasl Maenape EMetl By. Doalh ❑ Diw�ca ❑ AmWnceµ O Oate
Dale 01 dM wM1fMO py: O Bvt� GeNfrate O{t�tt (SpaGly)
i
!A
I t)J
1. Are yvu row� a taw you ever Eem aep[IgaC m x ol unsounE erinS/ No� Ya ❑
It ancwer's yq' Aas Ne aEjWiratlon Caen remove07 No ❑ Yes ❑
2. Ne �au rtlatea m uw'mele aDp�t cbw wn semM muvn4 Na � Yes p
J. Aro pu mw �ufper Vip uipuMCC 01 an alcWqlk percryoT NoJ� Y6 O
�. Are yo� row unGU U�e in�uence al a roRac Mg7 N� Ya ❑
5. list NO fW �urtrs ol any OepeMmt tlupren.
fi. (a) FuA lame ol app4aM's hNer
(I( aEOWcd. 6n AEOGIi+e Parents d^�Y) _
Raitlmce o! IaNm (J OtteaseE. w atate) n
BiN�placao(faNmlStaleabreq�rmWry) /�"�
(��FW maqrn wme of appGan�'s rtM�
(II aEOpIM, tiN /doGlivc Parents QN')
RaUmce o� moNa (I Otteaeq sp ytate)
BiMpace ol munm (SUta w breipn muwyl �i+.--
ACKNONIEDGMENT
� aw,owleape w� � wve refa'nea Wwmatbn rogarEtrp aenymous mmmwuode aseues
tl�at ara sezuaAy trarwritleG. enE a 5s1 al I�e tesl sdas /w e vuuz W t caus� ND acpyireE
immuna CeGtl¢nry s �
SignaNrnolApplion�� Dale°Z�
The aDOVe apd�mM tis o7jeUeE to venlyvq Gy paU or a/fumaGan m signaNre lo O�e :WOVe
actnowle0gmmt Eerausa ol reGgo�; Oe6ots.
Gak ol Coun pa��
Slale o1lMiana � I sxvarlaRVm WI Ne iNOertu�qn 9rvrn
Gounty d � �y� J as. in Vus/ a�ppWtion rs We aM mrteG.
SigneO /`r1 � 1V l 1 1\.l�y �� \ 1�� 1 A �
NewFOatess �
SuOSC�cG an0 sr.om m Debre me U�¢�Eay af a�Q!
ol Ne CaLson Cvcua Gwn
PARENT, OR GUARDIAtJ
We. Ne paRntS ol Nis applifdnl �ereCy Bive tqn5tty Ipr Ilis martidge. C wJr one pyreN sigM1t.
slale lacls wfiiU� maka Ilie consenl o( Ine ol�er w�ml umttessary
Staleollequr�a �
Govnly o� ) u.
raintt �p p _
Molhc � ID R _
SuCwiEeO anC s.vm m Oebrc me ilia _ OaY o( '_
pak
COMPLETE IF MARRIAGE LICENSE ISSUED BY ORDER OF COURT. A marriage license having been refused to the above named parties, the
Counry Court, by wntten order issued
and filed in , authorizes and directs the issuance of a marriage license to the above named parties.
- RETURN OF �tARRIACE LICENSE AND MARRIAGE CERTIFICATE
/
was filed in my o�ce a niar�iage /icense
marriage
- �� (smte) were
Cireui[ CourA�o(Gib�(bn CounA: Indiana
by �he�'lerlh- oj�he Circyit Coi�t ojGibson Countv, lndiana.
was ftled in my o�y�,��,7"� � � 1
�, er jy that onY1�3i �O0 (da7e). a7 /T
� oj CounN
oj ,e�.i+.e-� Cow�q�,
� rzsfJ uthori,.ed under a marriage license rhat war issued bv rhe Clerk ojthe
.G(�L4yt�-L �o . Z 6 O �
Signed by: " (o�cia! designation)
�Filed and corded in accordance with �he laws ojthe Sm�e ojlndiana on 3� %� 07 (d�areJ.
Sivned w��"'"""""�"-'' Clerk
� Gibson Circuu Courr
� /lYLA�IO.Ir �••�+�
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