Marriage Certificate - Mellon, Robin M_9/3/1999t�.�x .
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STATE OF INDIANA
APPLICATION FOR MARRIAGE LICENSE
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IC31•7-9-1. Fumishlnplaltelnlormellonuponapplyingforlicen�e.
A person who knowingly furnishes false information to a clerk of ihe
circuit tourt when the person applies for a marriage license under I C
31-7-3 commits a Class D felony. �
MALE APPLICANT
N�ms Fuat GEb lu
O�uo1B' 1AnnN 3Y Ya�r
P�n W�rtt[� (S�ta or lon�qn � nt71 � �
3- A.J
Rnkmp AEC Slr t or R. Ciry County State '
93y�,.��n�.C�,�p �' c�na,ti� o�+
Pnvipy� AlsnLl $taNf: Nemr MvtlN Q OR No. ol Greviom Merriagp �
LulMUnaq�ErbseBy: Os�In O DMOrc� �nnWment � D�Ie
DaU ol Din� v�nlieE Ey: ❑ Binn Gniikrte ^ Ot�er �SDeury�
1. An yov now or ��w you snr Men �EjWqW to De ol enaounE minC? N Yes ❑
II �n�or i� yn: �u l�� �GNGiution Dwn r�moveEt No p/ �es p
7. Ara you nit�C lo iXa �emale �OO��un� close� I�an sewnE <ouaiR No�ee O
7. An you now un0er I�e inlN�nn ol �n alc0�olic Eeveraqe� No /va ❑
/
l Me you ro. unEer ine inBUence ot e narcolic am9? No [7 vee O
5. Lia V unn�mnol�nyOSM brm.
i �9 Q 1T�j
fi. ��) Fun nams o1��pob���'� btM� � �
(If WopllO.lisl AOap�ive Ganntf Only)
ReeiWnc�ol�amsr(iloxeexo,weqtt� �_
Binnplacaolhmer�5bteo��onryncw�n�tQ\'�
(p) Fyll matl�n n�me ol �pD�K�nYS mo�Mr � � y�
QI �OODteE. li�l �OOOtiq Pu�nU OnFy) �Y �
FlfbGOtlOITOIM��iIdKC�H0.303b�l) _
Binnpl+o ol moIDer �54te o� Iornpn couniry�
ACKNOWLEDGMENT
1¢4nod�Ep� t��t I ��w receireC inbrm�lbn re9�rEin9 Eanqerom communi<eple Eneuea
t��tve�e�u�1lyV�mmineC. nE�liatoltne!{YQ�leff i evirmmucaveea�iDS�aca�irea
immun� O�tki�nq �ynErome� � [�p
� l \/ � /', O
$ipnt W t� 01 AOD�k�M Oa��C
TM �Dm� tppliunt Me ��cl O � veriryiig CY onn or �nirma�ion or signa�ure m me �DO.e
¢knoMilOgmanl EaCauu ol reliqi0u� pelieb.
pN OI Court Oate
SleteallMiem I IfwurhtlirmVUtt�einlormationglv�n
Counh ol GiOaon � 1 "' �„ IO IbII ]DOIKdI1M If W! �I1E W!lKl.
Siqnea
W. AEOi
al Ne Gibwn Clrcuil Cqurt
GONSENT OF VAqENTS. PABENT, ON GVAROIA{J
We, l�e p+renb al Ni� eOD�Ken1, �ereEy Oive caNenl br I�is marruge. II only one Oarent figni
tl�U M1cb wniU maka tlie conunt ol IM otnar pemnt unnecesury
Sbu al Inaian� �
Cwnryal � u
hNer ID �
MONa� �p �
SuESCnCee �ne nvpm Io oelora me mia _ oay ol 19_
Gerk
N GOUNTY
No.
File
�-�-98
Date ot AppliCalion
Female Applicant 50 > No ❑ Yes ❑
II No, Medical Exart�t1pK� o ort �_
� Name of Physician Y1Ly
Name � Flnt MIOEIs
l+al
�elaol8irt� 1 Mont� �
L1 ��Y /� �
1 1n
Plece2 ytq�5dte ar toroiqn country) �
Reyp�Qg aa� treetorR.R. Ciry unt� 54t
�r, a .,.ta _ QC�'a_r-l-,c/
Grerioua Matltal Steluf: Naver MarriM p OR No. ol PreHOm MartiaOn � I
L�siMarriageEnaeaBy: Deatn ❑ Divorce [f�An I ❑ p �
Dale al NM vuilieC py: ❑ Bltlp Certilica[e O ONer (Spe[Ily)
�I J„�1 � /J�A � 1= �:. /1 l
V
1. qre y0u now ar �ave yoa ever Deen eC'ryEB� lo E� ol unfounC minU7 N r Yo O
n answer ia-yea,-nas me aajoaiutbn oeen mmoveel No ❑ /Vee f"
t. �re you relateE to Ifie male appliwnt clour I�an aeconE cousin? No L� Yey�
�
J. �re yoe now unEer t�e inlluence at en akanolic Eevenpe9 No PP/ Ye�'❑
l Are you now ��er O+e inlluence al a mrcotk Emg? Nob Yes O
S. il�iT[�e tvll nemp ol a(ry aepe�aem cnileren, _.
6. p) Full na� ol applicanCf la(�er
pl �EOD�eO, lin AEOO��'e Parenls Only)
RpiOen[e o1laIDer (il 0e[eafeC, so state) _
Birt�pbce ol IaVier �Stele or lorel5n wa///n���try)
�E� F�II m�iEen name ol aDO�����'� moNe�
(II �OOD�M. �ISt ACOplive Parcnts Onlyf
RniEenc<ol mot0er (ii EeceaseC, ao i�stq _
Birtnolace ol mot�er (S�ate or toropn country)
AGKNOWLEDGMENT V
1 acknowleCqe tnal I pave receivea inlormalion mgerOing Oengerom <omm�nicaple Oixa3es
�Mt are se� W Ily �rmsmiReE. anE a lisl ol l�e Ieal Ytes lor inC HNa iMl causef �IDS (acGUiretl
immuneUelicienrysynC(\o� �` //� 1/p
Signawro ot ADO��um �/ �� ✓�1 �✓%j/�^'fl oa'M �/�/
Tne a0ove epplicant M1fs a�jecieE to verilying py oal� or ellirmatian or signa:um lo ��e aEave
+c�nowleUgmeN pec2use ol religious Eeliefs.
Glu� 01 Co�n Date
StateotlnEiana 1 I�wevhuirmtMn�einlorm�GOngiven
Counry o1 GlEaon �� "' �� ���a aooi�u�be h vue a�a w..ea.
Signea
arG
GlESOn Circuit Coun
GONSENT OF PARENTS. PAflENT, OR Gl1ARDMN
We. t�e Oerenis o� I�ia applicanl, OereEy give consent lor inie martiage. II onry one oarenl signf,
ftate IaUS wnicn make t�e consenl ol ��e ot�er Oarenl �nnecesary
St�te of Inoiana �
Co�n�Y ol , ss:
Fe��er
Mo1�e�
SuESCriOeE anG sworn to Oebre me Nis
ID •
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aayol 19—
Clen
COMVLETE IF MARqIAGE LICENSE ISSUED BY ONDER OF COURT. A marriage license having been refuseE lo the above named parties, the
Counry Court, by writ�en order issued
end liled in authorizes and direcis the issuance of a marriage license to the above named parties.
RETURN OF MARRIAGE LICENSE AND MARRIAGE CERTIFICATE
I certity t6at there was filed in my office a marriage license ued 6y the C]erk onf the Circuit Court ot Gibson County, Indiana,
dated 1 ,,,J�` , authorizing the msrriage of �-�+C_��I1l��o1CXl �' l �d
cltin. N111r'1 � ir(r /`� U `•,
I further certify thet the folloming mamage rertificate was filed in my
(, �P�}lM. �, n�,d�o -�fname). certify ChAt o�
'1 Caunty, Indie �
� (etetel, end �
i �� (atate) were mam
Circwt Caurt i6son County In ia dated
Signed br• ���__.
aa
ce:
5 raee��, e ;�
of County,
of �� County,
under a marriage lice�se lhat was issued by the Clerk of the
(official designation)
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