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• STA7E OF INDIANA •
ANPLICATION FOR MARRIAGE LICENSE
GIBSON
IC31-7•9-1. FumisAlnplal�elnformaflonuponepplyingtorlieama.
A person who knowingly furnishes false information to a clerk of the
circuit court when the person epplies for a merriage license under IC
31-7-3 commits e Class D felony.
No.
File
COUNTY S— �� 9S
Data of Ap0licetion
Fema�e Applicant 50> No ❑ Yes ❑
If No, Medical Examinat� or Repor7 Da ed
Name of Physician ff
MALE APPLICANT I FEMALE AVPIICANT
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•CKNON'LEDGMENT
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•LKNOWlEOGMENi
I�ct�w.IW9� t��l I Mve rsceNeG intomution rp�N4ry Gtnperouf cmmuniuW� Ulu�fea
iN� p1 �uu�lly IrammitleE, �nE e list GI IM Ilft aiba IOr Ne rivs l�tl qu3P AI�S (aCavinC
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TM �EOV� aDW�unl �u ODNtlM lo v��IlylnO �Y o�m or �Ilhm�tion or upmtun to Ine �eove TM �pOV� �pp1iCM� �u aElec�eE to vetllYlnO �Y o�t� ot �Ilitmeli0n or fipnaWr� t0 ��e �OOVt
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CqNSENT OF GARENTS, PARENT, OR GUMDYAN
Wa.l�� p�nnb ol Nb tpDlk�nt. �a.aDy 9ir! cMxnl lor t�if marri�0�.11 only one oerenl sipns.
Nb I�ch wTk� mak� iM wnunt ol iM o(ner puen� vnnxovry
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Counry o1 GIEam 1 H' � I�u aDGli�tion ie tru� �nE correct.
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LONSENT OF iAFENTS. PwRENi, Oq GUARDInN
We.lna 0����� a� ���� eOD���4 �ereby qive consen� lor t�is m�maga. ll ony oro W �M�t sp^s.
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Stab Of IMiaN 1
Gounryaf � °:
FtlM� 10 •
MOI�I� ID �
SeD�ctlOeE �n0 �wom to Oatore me �ni� _ Oay o� �9—
Clsn
COMiLETE IF MARRIAGE LICENSE ISSUED BY ORDER OF COURT. A marriaga license having been retusetl to the above named Oarties, t�e
County Court, by written order issued
end filed i+ authorizes an0 directs the issuance of a marriage license to the above named parties.
RETURN OF MARRIAGE LICENSE ADID MARRIAGE CERTIFICATE
I that fhere wes filed in my office a marriage /irenae iseoed by the Clerk of the Circuit Court ot Gibson County, Indiane,
dated �, authorizing the marriege of �L.1._LtT�,fF�/�-�� � � and
l
I f u ce�j fJ�,that e follo�g memage certificete mes filed in my of 'ce:
I, �,�_�/�j/ �.,�w �..V (name), re' thet on y (dete), et � e �� in
� Caunty, Ind(ana, of i��F+Ay'��"�' County,
� (atate), snd �; • "'� ✓ of Xhlsd�� County,
��� (atate) were marri y me es a o zed ¢nder e merriage licenae that was issued by the �Clerk of [he
Circuit Court ef ('y'6son t�M'�e, � _ /
� /O�L_.
Signed by. (otncial designadon)
Flitd end recorded in attrordence wit6 the lewa o the S te ot Indiene on 2�%' i95 (date).
Signed Cler4
,vyi„vvn i wivo ibson Circuit Co t