Marriage Certificate - Rogers, Vicki_11/16/2007FamPn �OeCBy
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• STATE OF INDIANA �
APPLICATION FOR MARRIAGE LICENSE
GIBSON COUNTY
IC 31 - 7• 9• 1. Fumishing talse hAorrretlon upon apply6g for Ilcense.
A person who knowingly furnishes false information to a clerk ot the
circuit court when the person applies for a marriage license under IC
31 - 7- 3 commits a Class D telony.
MALE
Name t
Dale ol 9vV� Alpn'
_. Race ol BiM (5 r Iweign country)
�~'����
Revious Manfal5pqa: Navar MarrieQx O
oay
SaTe
No. ol Prevbus Marthges
LaSt MderuOa ErWBE By DeaN ❑ Drvwte ❑ MnNnenl O Ddb
Dale W Oinn ver5ea Cy� �CerNia�e�M)
t. �re you row w nave you ever Deen aEpdgea b be ol u�urW mnG? No� Ves Q
II ee�sxar a yes' has Vq a0rydicatbn Eean remove0? No V❑ Ves ❑
2. Are you rehMO b Ne leirele app4mnt cbsm Vmn secoM musv�? No U Yes a
3. Rre yvu now un0er Ne inlluer¢a ol an alwholc Oeverepe? No (k Yes ❑
�. /.re yw mw uMer Itre iNluence W e re�m1c E(ug? No� Yes ❑
� 5. LW iM M remes o� anY aeGenElfq WCren.
�
2
F
Z
a 6. (a) FuG reme d apqimn�'s IaNer
¢ p� eaopte0. fct ndopwe Parerqa qyy)
a Ra5i0enca W kttier (��1 Eec�seC. so stata) �
BvuWlace ot tanur (Smm or Iweign ramtry�
u
(DIFUO �iEm reme al epplrant's moUne
(II eEOpbC. Is� pdoptive ParenLS ONy)
Resioerce oi motner (d Oeceasea. m sab)
&Mplace ol moNer (Sble or foreqn cauntry�
ACKNONIEDGMENT
I xkrowletlge Uat I have receiveG iMo�maUon regaNing tlangerous commu�We tlaeasrs
— Nai are seRwOy traismiMed, and ai' of Ne te t sites br Ihe wus N uses A
' vnmunetlelrierWysyMrom
i SigreWre ol Apqicant _ Date
Female Applicant 50 > No �
If No, Medical Exami ' n ol
Name of Physician
No.
File
� �0
Date o Application
Yes ❑
4b�
�—�
Name l�A�li� i� � �L,O'�li�(.CJ �
Date ai Birtl� Monih O Y Ye
Q
Placo ol BiMn ( ' or braipn counq)
f'n $tr w R `y Co SId19
7
Previous Mantal Status: Nevar Martiatl � OR No. ol Revqus Martiapes
Last Marre9a ErdeE BY DeaN ❑ Diw�ce ❑ Rrvw4rent ❑ Da:e
Dd1B OI DvN vBrfbE Oy: � BvN GeNlkeq ��
n /
ll�V r
+. �e rW �«��re ro� a�• e«� ae„,eyae m m a��e �,:�w� No/q Ves o
II enswer's yes; !ms Ne aE�W kano^ Dean removaC? No 0 Yes ❑
2. A�e yw re1ab0 to tM mab eppiwn� cbse� tten semM musn? No� Yes O
3. are you now unCer Vre inilueme of an ekoMtic paverdge? N Ves ❑
4. Aee you now uMer Ne in'JUenca ol a�aemOC Orup? Yes �
5. Lst Ne tuA �emes ol any depeiMent Wtlmn.
fi. (a� Fu1l r�artg o� applFanCS IaV�et
(Ii a0op:e0. fig Mopme Peren6 ONy) _
RasiOance ol kNer fi aeceaseC. w spte)
Bvuplace oi hmer (��e w bre4n munvy)
(D1FUll meitlen �ma ol appkent's rtqttiai
(IiaEavcatl.GC�AEwVmrePamntsOnN) � y��
Pesberce o� momn 01 OeceasM. so rta�el s�/—
BiMplaceolmoNe��SpiBO�IWeipnCOUntry) �
ACKNOWLEDGMENT
I acknowledge Nat I have rxeived in:ormatqn reqardvg Eargerous cammuncable tliseases
that are sezial IrdttSrtiRled, antl i510l Ne tes Si,l$� iw Ne virus �lat causes A1 $ w
immune deficiency ryMrome) ' j/�
SignaWre W Appicam "" Date � �
The abOVB dppliCdM has objec�etl �o v¢nTying py 03th Or 3Hvmaipn o� sigraNre b NB 2bOV0 The aGwe appl�rarrt tus objectatl to verily'vg Oy oaN or aHirmalian ar si�aNre to �M aDwe
ackrowledgmeni Oeause of retigious betieh. y�krqwltygment be�auu of religpus G¢liels.
Gerk of Coun Data GeM o� Coun Date
Sta�e oi IM�aea
��
Ner
� 1 sweer/alivm Uvt Ne infomution piven
� 55. T b16 3�5GW(16 hllB Blb WlfBC�.
�ie 3
k ol ttro Gibmn Cvadt Goun
CONSENT OF PARENTS. PARENT, Ofl GUARDIAN
We. Me pe�en5 0� N¢ applicent. Irerepy giva mnsen� br Itis martupe. 1� my me paront s'q�a.
stele facts w�k� make Ne consen� of t�a ot�er perent unnecessary
SUte ol Inpmna �
u.
Fa�her
SWSCriO W aed swam Io Eebre me uis _ Cay ol
ID •
ID •
Gerk
Sqb ot IMmrm ) I sweerFelivm Me� Cn woimeUpn �ven
Counry ai�;, � w. In U:s eDD�ton's we ana cmac�
�������..� Qo �,R-,��---
New REOress ]� �
5 anE sxom b tore me Nis Cay ol ,�H/+�
Gark d Ne Gasm Gicutl Cow
CONSENT OF PARENTS, PARENT, OR GUARDIAN
We. Ne paren5 ot Itis nppl�nt. Mre�y 9rve msent la ttvs �rtvge. II mty ana parent vprs.
stata lac6 w�icJ� make t�e consanl o� Ne oNer parent unnecessary
Smm oi IMere �
s.
FaMer ID � _
Mo(I�er ID � _
SibscriEN aM s..vrn ro Eefwe me tns — aaY ol .
Cb�k
COMPLETE IF MARRIAGE LJCENSE ISSUED BV ORDER OP COURT. A marriage license having been refused to the above named parties, the
County Court, by writlen orderissued
and filed in , authorizes and directs the issuance of a marriage license to the above named parties.
I RETURN OF MARRIAGE UCENSE AND MARRIAGE CERTIFICATE
l cernfi� that rh e was filed i�� mv oJfice n marringe (icense iss�/ jd b�� the Cferk nof th�e Circuir Cowt o/f�Gibson Co�mrv. lrulia�m.
dateA�� 9�3 , aurh i-ing the rwrriage of (��}�4 GJ'- efsm.n-�a_c+�1; mid
i/. _� •. � �.�_ _
l ju�(her certi(��•
l.1L�
certijunte was filed in my
�(uame). cer�ifi� that
eP�-.- (smtel. and�
� (srate) were married by
Circuit CourG of Gibson Com�¢}t lndinrm, dated—
Sigued b��
Filed and
ojj; e: •
on �(date). at %��� =-'� i�i
w�..�.c..r.� oJ �..�..,... counry.
of�--• Counry.
u�ider a marriage lice�ise tha� k�as issued by the Clerk of the
(o�cia( desigiwtion)
accordance with th"e (aws of rhe Smte of /nAinna o�� -s (dnte) •
, �
Signed ��t- � �{�+1�4� �^ Clerk
,.,'.���-n r•;,,,,,, �. ° � e