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STATE OF INDIANA
•PPLICATION FOR MARRIAGE L�SE
GIBSON COUNTY
IC71-7-9-1. FumltAlnqlalselnformationuponapplyinglorlicense.
A penon w�o knowingly lurnis�es false information to e clerk ot Ihe
tirCUit tourt when t�a Oenon applies for a marriage license under IC
31-7-3 commits e Class 0 fetony.
MALE APPIICANT
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�CI(NOWLEDGMENi
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� Date ol Application
Female Applicant 50> No � YeiO 5 y�
Ii No. Medical Examination r Report Dated
Name ot Physician -
FENALE APPLICANT
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�CKNOWLEDGYENT
1�eYno.IM9e ��at I N�v rtCervlp �nlorm�llon �eq�Ni�q EaeqerW� eOmmuniGN� Oi�OW!
N�� tle fe�u111y V�nfmiXW. �rq � 4f� OI N� �MI fl�n IOt IM rvuf N�1 C�YMf �Ip$ (Kpvi�W
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in� �ppv� �oG�kanl Ma oCj�tiW le r�nlYinq pY wN a�Rirmalion er aip�ulun lo N� �tar�
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CONSENiOFG�qENTS,VApENT.OFGU RDII.N
Wa.11ia pv�ntf ol Ctif �pqi[ant nenGy 9�H cpnxnlla fNa wmuq�.11 m7�� WRr� K^a.
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Coun�y ol � u.
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MONf� ID•
SuoacrieW �M �.om w pelw� ce m1a _ Eav ol f 9_
Gen
E ISSUED BY ORDER OF COUflT. A marriage license naving been reluse0 to lne eGOVa nameE Derties, tne
Cqunty Court, Ey written order iseueE
aui�orixes ana Cirects Me issuante ot a marriage license Io I�a sEove neme0 parties.
RETURN OF MARRIAGE LICENSE AND MARRIACE CERTIFICATE
1 rertit Ihat there wav filed in my office e mertiege lirenae issu 6y Ihe Clerk of th/e/�JC�ireuit Court of Gi6son County, fndiana,
dated S �, n , authonzing the �mjarriage ot� �"�—�- �- Ld /�� �d
4a7/i..<._ i . � , .L-f-. _��_l% V
I further ttrtify the the follo ' g m ege certificete was filed in my offirn/�:� ' �
1� -i`� %� n (n e), cer4�f�y Nat op �(date). at �� in
ounty, Indiana • �� �� of Caunt
� `3p Y
o (ste[e), and �n.. - of County,
p� (stete) were mam 6y me es au[honzed under a memage lirense thet was issued 6y the Clerk af the
Circuit Cour f Ci6son Cau ity, Indien , da ed�6 .
Signed 6y: /� � (offitiel designetion)
FSled and recorded in eccrordenre wifh fhe laws of [he Stefe of Indiana on `�R- 6� �°`rd (da4).
Signed Clerk
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MAR � 7 2003
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