Marriage Certificate - Tichenor, Laura Beth_7/3/2003F�P2��r OO S�� a� y��SfATE OF INDIAN•
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"°'�""°°`"'°°" APPLICATION FOR MARRIAGE LICENSE
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��--1 i �� � GIBSON COUNTY
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IC 31 - 7• 9- 1. Fumishing lalse Infortretlon upon applying tor Ilcense.
A person who knowingly lurn���s Idse If�lB�tion to a clerk of the Female AppiiCdnt 50 > NO �
circuit court when Ihe person�applies�for a marriage license under IC �f No, MediCal Ex minO�iOn
3t - 7- 3 commiis a Olass D telony., /� n Name of Physici
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NamE
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DataolBvN ManN 6ay � Vear
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aiace o� eiryq5ra�s o� iweqn muntyj. �
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PreJa�s MaAtlIStaNS: Never MartbE ❑ OR No. ol Pravbus Marreges ��
Lasl AM1arteqe ErtleE By: DeaN O Ohrorce Op rlmNmenl ❑ Dale �
�ata d b'uN ronfcetl by: � 01�Ih Certiliple O 011rer (SOK��Y)
1. �ra you now w Mw you evei Eeen atl}MqeE b be d u�ounE rttlrM] No-F] Yes �
I� enswet k yes,- tus No atl'ryEicalbn Eeen �ertpve0? No ❑ Ves O
� 2. R�B yw �elateC b Ne lemale epp6mM cbsn tlmn secoM cousin? N0�9 Ve5 ❑
3. rlra yvu mw urtler Uo Wluence W en akotpi[ peverage? NT9 Yes ❑
� a. ae you row wke� Ne inlluence ol a rorcotic a�uq? Nda Yes ❑
n � � remes d am/ E ntleN CtYOtln.
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a 6. (e) FN name ol eGO�n�'s hU�ar'�� ��
r (11 aEOORE. fst AEOO We PareNS O^iYl� -
a Patlerce al hNer (il0eceaze0. m s:aie � 1'-'���'
Btrapam W iauw� �Sraie w �weqn ) =+--+/
(�IFU��iEenremeofapp6canl'smoc+e� �
(II aCOp:eE, f¢I Rtloplive Parents ONy)
aeseerce oi momm ry e«easea. so sta�el ln s� � �.1 �—.� T�
B"cttplare oi motnar (Slata oe l«e4n counbY) �-'• J
ACKNOVJLEDGMENT
I azkmwleEge Ihal I have receivetl inormalion regartling Oangerous commurvcable tlrseases
Ih21 are sexuaYy Vat�smitl2tl, an0 3_ti5t 01 �he� 1� or ih^+irus Ihal tausts AIDS (acau'ved
immune Eeliimry syntlrom^` �- /%
SigrulureolApp'ranl-� /rewc:s (LL,s.» �,�-�C-e�
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File
D�`E' � - �+1—
plicatio6
Yes ❑ `/
,.e n�ee.� T'-� S-�o
Name F45t N �11
A . .N- 4� . G._.
DaleolBiM ` Mpnlh Dayn Year
ti- i r_ 1 �-7 n -
Pk ^ BiM (Sb1e or bre`yn wunvy}�
Re erce PtlEress yy� eel w Rry� CYy Coynry SU'
�y16`FH/� C�Jt�.e-�u�l�����i1���`�)
P�evbus Marllal5talu5: Nevee Marrle0 O OR No. oi PeeWMS Martiaqes �
Last Marrlage EnCed By Death o Dhrorce�a nmulmem O Da�e
Dale ol p'vN vertlieC py: �9'vi� CerNiale O ONa� (Spxity)
t. Are you now or nave you ever been ad�udgeE b De ol unsounE Mn0? NGS Ves ❑
Ilansxereyes,-hasNeaE'rydiralbnDeenremoveE? No0 Yes❑
2. Are you reWleE W Ne rtele appllt2nl Cb58r It2n SKOnE COVSin7 N8"J Yes ❑
3. !ve you now un0e� Vre influence ol an akoM6c Oeverage? Nb Ves ❑
d. Af8 YOU Mw Uf1�0t N! NIIUlMB OI d RICOGC C(Y3? N:❑ YPS ❑
5 "st Ne Iu1 remes ol airy Ee en0ent cMJ�en.
(,�
b. � W nxme al appll[ant's tal��J �
(11 aJOp1eE. is1 ACOptive Perentc ONy) - - --
Resiaence o1 bucer ry eeceasea, w sta�e) � V.a...A �� 1 �
BuNpace ol latlue (Stata w broign try) �
��E�FM maitlen rome ol appfcant's mol�x� �
(II atlapteC. h1 Atloptive ParenS ONy)
Reskenca ol eml�ee Qi EtteaseE. so atate) V ��/
Bvlbplace ol motl�er (Siale or beaign wunhy) �- AJ
ACKNOWLEDGMENT
I ack`w.Nedge iha� I tave receivetl information regarNng Oangerous canmuricable diseases
thal are seeually transmit nd a I¢� ol Ne lest ites b�r th�gvirus fial causes AIDS (acquired
immunetleficiercys � 8 (�/� ///_ / � y_z5_O1
Sigrewre w aod�czn � oa+-
Tha abwa appicam nas oCjeneA io venyug Gy oam or anvma�ion or signature to ihe abo.e T�e above appGCant has objected lo veritying by oath a aliirmatbn w sig�ature to Ihe above
acknowletlgmenl GerauSe ol ratigious petiets. ackrawlMgment Oecduse ol religiaus beliels.
Clbk 01 Couh Da�e Clerk ol Cwrl Dat2
Stat!
I sw¢arlal(vm W I Ne Inbrmation given
In Nis �p�iShcion is true ettl Cartet�.
New ApEres
swwn b bre me l ls � CaY o ._ �
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� ..5�_Gkek ol me GiOSOn Gvan� Coun
CONSENT OF PARENTS. PARENT, OR GUARDIAN
Wa. me parents ol vis eppGCanl �req 9ive misent br Inis maenage. u oN/ me parem sym.
stale lacls whic� r.uka Vfe wnsenl ol Vie ot�er paren� �nnecessary
State a Ina¢re " 1
County ol � ss.
FaIMr ID �
MpIM1lr ID �
S�IDwaea am swwn to xbra ma Ns _ day o1
Gkrk
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� Isxear/allvmWllliemioemationgiven
� u� YI IiYS dpD��u' �� WQ dfld CCl(ECI.
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New AEEress v
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antl swm b.J�elore�... � EaY ol ' .?
Ne Gbsm Cvcu.� Coun
CONSENT OF PARENTS, PARENT, OR GUARDIAN
We, iM parmts ol ms apptiran4 �emGy pNa mnsenl la Vtis martlape. II arJy one parent syre,
slate tacts w�icl� ma4e Iha consent ol Ilie oNer Darenl unn¢[assary
56te ol InCw�a �
r ���m„i i a.
FaNee ID �
e.wu�er io .
$�CSCriEM antl swrn b �elOt! me Nis _ Cay ol
Clerh
COMPLETE IF MARRIAGE LICENSE ISSUED BY ORDER OF COURT. A martiage license having been relused to the above named parties, ihe
County Coun, by wriiten order issued
and tiled in , authorizes and directs the issuance of a marriage license to the above named parties.
RETURN OF i11ARRlAGE LICENSE AYD D7ARRIAGG CERTIFICATC
1 certiJ}� dmt the� �vns filed in uiy oJfrce a mnrringe license issned by theiCferk af d�e
mrthori;.ing the nmrri�ge
1 fir , r cer�ijy dmt l�e fo!lo� �ing u rringe cer�ificate ivris filed ir� mv
�. (nn �e), certiJy t mt
Cow�ry. A�dinnn,.�
—�W (stnte). m�d __ . �_�
—� (smte) �rere inarrieA 6v me ns aut�oriced
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under m m�rrrnge
ajG�bsa� Com�n�. lridinnn.
—(dn�e). n� L� in
.
.of—}����✓" Camtv.
-oj—Ctv°—@ey`-' Countv.
dmt �rns issuetl b y d�e C[erk nf the
Circuit Cou�rr yo/jGibsor� Cou q•," l��d�ia-u`rrjj' dnnt/ed ��y��y-p /
Signed 6y: �G�-�_�¢� � /`-z vt� Q (o�cin! desigi�ntion J
Fi[ed and recorded in nccordnnce wi+h tHe Imes oJd�e Srnte oJL�dinim on ��._�DU.� (dnte). r
Signed_/�'""�°--- /�!/w Y, C(erk
� Gibsou Circuit Couri
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