Marriage Certificate - Jones, Amber N_9/16/2003��v
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• STATE OF INDIANA � No.
APPLICATION FOR MARRIAGE LICENSE File �
GIBSON COUNTY ateo�pp#cation
IC 31 - 7- 9• 1. Fumishing false informatlon upon applying for Iicense. /�
A person who knowingly furnishes lalse intormation to a clerk ol the Female AppliCant 50 > No Yes ❑ (1 -16 �C.J
circuit court when ihe person applies for a marriage license under IC If No, Medical Examina ion�qr Re o Dated ���
37 - 7- 3 commits a Class D felony. NamB Of PhysiCian l� �
' MALE APPLICANT
Name tr • Mpple
Da�eo18M MonT� � I paY � V
�
R a �� t� ta � lae9n muntry) �
�%��w� v� i or Gy, Co 'j� �/� l0�
�/ �� /�1��
Reviws Marital Sqtus: New� MartieE ❑ OR No. al Prtvidrs Marteges —
Las1 Martage Erdea By: Deam ❑ Or+orce Mnu4rcnl ❑ Daie
DaiadG4NVerLiMby. ❑BvihCerWkata er�Specily)
t nre rou row or nave you eve� been aEjutlgaE io Oe ol unmurM mnEt No� Yes ❑
' II amwae fs yes,- lus pie eEjWica Wn peen removeE? No ❑ Yes ❑
2. R�e you relateE b Vie fe�rele ap0�an1 cbser Nan secoM cousin? No� Yes ❑
J. nre you now uMn me iNAxnce al an akotpic Oeverage? No Yes ❑
��! d, A!! y0Y row ulq0t IM WNBnCB 0� 2 naf[otk tlrug? N Yes ❑
b 5. Lkt Ne hA `vmps ol a�ry OepeMenl phideen.
�
i
z
a 6. (a�Wnnameofeppfiram'cMtnar
¢ (1ladopteE.f¢tAdopWaPaeeNSONy)
a Reskence ol Ialner (J OeceaseE, so sute) —
0vuWlace ol lame� �Stata w lore4 �r01y) .
(p�FMmakannamaolapp6ranfcmotM1T� , `
(II eUOp W.Ilsl AEOpttva ParentS OrYyMi"'
ResNance ol mo:lrer (C Eec¢asetl, w slate) _
BvNplace ol mpNe� (Sqle w loteyn country)
ACKNOWLEDGMENT
I acFUqvAetlge Ihat I rtave receiveC inlormatbn regartling �
Wt are sevua0y trarsmitted, an0 a tist oi t�e iest sites Ip� U
vnmure deliciency��an� ! ,
9graNreolApdira?./ . Yv/I,,,r V
us wmmueJrable diseases
Ihal u es AIDS (dpcquireC
. � "'�+"'��
ihe aEwe a0p��� �as o0jected to ventying Oy oath or affirmaUon or sgnaWre to Ihe above
ackrowledgment Gecause ol religious beliets.
Gmk ol Go�n Oa:e
S��a���^��^� � ISweaqalltrmlhatNeWOrmatqngiven
Counry ol_ _� ss. n tNS appGCa4on Is true arq wnect.
59Mtl n�� 1 h. t/ ,�PJ �//
V '
� NewAtlOress I!'� J�,_ _�_ i ��'i_
ol Ilie GiCwn Gvcuii Cour1
CONSENT OF PARENTS, PARENT, OR GUARDIAN V
We. Na paients oi Nie applkant M1eieCy give mnsenl br i�a marriaga. 11 ony me oarant sgns,
sta�! lacls wplC� ma4e Ne cOnsenl ot I�e ol�ee paren� unnecessary
Slate ollnEivu �
Counry ol �
MOtM�
SOttriDeO anC smm b bebr! me W
ss.
ID •
ID� _
CaY ol _
Clerk
FEMALE APP
Name
Daie ol BvN
chce al B�n (Sq:e or br� cwnry) . �\ „. /{ r.
Peevlars ManWl SU�us: - Never MartigE� OR No. ol Previoui Marziages
Lasi Martega EntleE By: D�N O Diwrce ❑ ArnWmenl ❑ Da;e
oaca o� bcui ve.niea by: ❑ evui cerWra�e�GO:ner (���r)
�� A �/VlQ Q �
L Are you �ww ar have you ever been adryEqetl lo pe ol mnoun0 rtdM? No Yes ❑
II a�uwe�'¢ yes,-has Ne eQjuOica:lon been removeC? No c Yes p,
2 Are you reWletl lo Ihe male applican� cbsar Nan sewrM cousin? N/oz //Yes O
3. Me you row untler Ure influence o� an alcoloGC bew2ge? No�2'/// Yes O
a. Are you now ontler the inlluence ol a narco�k Erug? N.Z Ves ❑
/
s. ��I �i i1�r�n�.ma� ��U,�e�.��
OL �
fi. (a) Fu0 nama ol a0p��� s faNer �^n ^ . \�,�,. ^ ^ �
pl atloo�ed. Gct neoowe Pz�ents ONyI — Vl� nvlW^.,V�__�`��``L�'�X�L!
Re5lCence ol �aNe� (II tleceasBO, So Sla�e) �_ `� v v
&Mqace ol latner (Stata or lomgn mun'.ry) �
(E)FW maiden nama al appFan� s rtnNer �
(II aEao��. �s� MopWe Parant5 Onty) ('� �
FesiEenca ol moNer (J Oeceasetl, w state) �--+
BIrl�paceolmoYmr�Stateo�bregnwuntry� �
ACKNOVJLEDGMENT
I ackmwledge ihat I have receiveE in:ortna;ion regardirg dangerous commu�iwWe Ciseases
that are sezualry IranSmitteG, a a Ist ol ihe lest sita br t�e virus Ihat causes A' S( cqu'ued -
immunedeficiencysyndrErje) ���/
Signawre U Applicant 7�� ,u �___ 'L pate
The above appticanl tas objecieC to verilying by oaJi v aftvmauon w signa;we to Rre aEOVe
ackrpwleCgmem because ol religious Gelieis.
Gleek o� Cquri pa:a
Sa�eallMiaiu 1 Iawear/alfumNa�NeiNarmauongNen
County oi ) ss. in Rvs app{raVin 5 We aM conecl
��� �c�_����
New Atltlrew • e— .. - A .
ina GiDSOn Gvcua Coun
CONSENT OF PARENTS. PARENT, OR GUARDIAN
1'!e. Il�e paeanis ol MS appliwn� �erePy gNa cansent Iw Ilds martiage. II ony ore parent siqre.
sla�e lac6 wMCh make ��e consent al Ne o0ie� Oaren� unnttesury
$Nbotindoeu �
CAUnfy01 � 55.
ramer ID+ _
MoNe� ID x _
SiMUibetl aM svmm b belOre me Na _ Eay ol ,
Glerk
COMPLETE IF MARRIAGE LICENSE ISSUED BY ORDER OF COURT. A marriage license having been retused to the above named parties, the
County Coutl, by written order issued
and filed in , authorizes and directs the issuance of a marriage license to the above named parties.
RETURN OF �tARRIAGE LICGNSE AND \1ARRIAGE CERTI�ICATC
l certifY � mt r/iere �oru file�l in m�• oJfice n rnnrringe (icense issued b��� 'he C(erk oj �he Cira�it Co,urt /af GniGs�on Cawitv. (ndiann.
dnred ���'�_ _� j. nud�ori;.ing the marriage of___���`� /�+—��t�+-� and
� �- - � i 1„ n
1 ft� lher cerlifi�
/.�
Circuir Q
Signed Gy
Filed m�d
Y1Iii�
was filed in my o�
I.,certify diat on
smtel. m�d L
i��...� r•�
�� (smte) n�ere mnrried me a.s nut/iori;,ed ��der n mar�inge licei�se d�at �nns issued Gv the Clerk oJd�e
Gibson Comth• ndinna; dnred!��� 3 '
- � (ojicinl desig�mtio��)
!�ccordance rvith th aics of the Stare of Indiann a� -i���/-�21? (date).
Sigi�ed �x�Yf�`' Q.1,��-',^'?"^.,^�'o^ C(erk
Gibson Circni7 Coivt