Marriage Certificate - Townsend, Vicki_11/16/20074u�
'°'"'°an°°aB� • STATE OF IN� NQ.
m.�. s�r evm a
NsNiiei"'�°" APPLICATION FOR MARRIAGE LICENSE F�ie q
acm.r.o
GIBSON COUNTY a��p��at�
IC 31 - 7- 9- 1. Fumlahing false Infwmatlon upon apptyUg for Ikense.
A person who knowingly furnishes false inlormation to a clark of the F0m21B AppliCant 50 > No Y05 ❑�
circuit court when the person applies tor a marriage license under IC I( No, Medicdl Exami �On ol RBpO le
3t - 7- 3 commits a Ciass D feiony. Name of Physician , ��
MALE AP CAN�
Hame s� r e
DalealBVl� Monl � Day� � Year�
/
Race ol &M 1 4� �weqn coun WI
HeviousMaeih156WS: NaverMartindY OR No.alPreviwSManegn
/�
last Marriaga EMeE BY �eaN O Drvwce ❑ Mnu4nent ❑ Dat¢
Da�e ol Einn veriSeC C�' �CarWirala �Otnee (SOecJy)
�
�
1. Are you row oi tave you evar pean a0ju09e0 b Oe ol unmunC mvq? No� Yes ❑
II amwe� 4)'BS: lus Ve aCiW catiOn pean rartaveG? No �❑/ Ve5 ❑
2. Are yau tBbIBO b Na larteb applK2ni cbser Uun sat'nM mutin? No R Ve5 ❑
3. nre yrou mw uMer Ne'uJlueze ol an alrotnfc Deverage? No l� Yes ❑
�' �. PIB y'pU IqW IIMB! IIIB NINBlICp OI 0 NICOIC OM1Ig� N0� Ves ❑
� 5. LN �1e hm'umos ol any EepenEAiu ctiiEren
ul
V
Z
F
Z
a 6. (a�FWremedappfranfsWiner
Q plaaopW.ici�tlopiivePawntsONy)
a ResEe�ce d kNar (il EeceaseC. sp ya�e) �d--
Bivqlace ol falnee (Sm4 w Iweqn m�a�ey)
(EIFUO iretlen reme o� app4ranfs mottier
(II WopieC, Ist AEOplive PareMS Ortly)
Resioance W mome� li� aeceasea. so sra�e)
BvOpkce ol moV�er (SU�e ar �oreign counpy)
ACKNOWLEDGMENT
I ackrqwleEge Wt I have rtteiveG iryomiation regarUing dargerous mmmurti�aWe Oiseases
Inat are sesua0y trarsmined, antl - ol ihe te t si�es lor Ne wus In uses A S cq � e0
immune delidency syndrom
Sigratura ol Apptirant � Da1e
�e��a ��5.� �g—� � �
6JIeoIBitlM1 Monl�b ay Yg.•
6
PFace al BiM (5� oe breyn counhy)
Str � wPR $Wt8
Prevbus Manlal $talus: Nevar Ma�ried � OR Na. al Ravbus Marrgpes
lasl Narr¢pe EMetl By: 0¢dlh O Divorca ❑ PmNmBni � Date
Date ol D'uN vertlie0 by: F BiM Ge� �ONer (Specily)
5vV �r�r—�--
1. Ne you raw w luve you evee bpen atliutlge0 b Oe oi uirsouM mvM? No� Yes ❑
Ilamwr'syas,-IiasMeaEjWira4on0eenremoveC? No� Yx❑
2. Ne you relateG b u�e rteb eppliran� cbsae Wn secanO couvni No� Yas ❑
3. Are you row un0er Ne inlluen[e ol an atvinGC Eevarage? N Ves ❑
a. Are you row un0er Na inlluence ol a rercooc ErugO Yes ❑
5. Lst tlw lu! remes oi any tlepeMant cNNren.
6- (a�WllwmeolapybanfstaNer
(II aOOD�aC.4st ACW Wa Peren6 ONy) _
ReSiCarce ol kNer (J aeceaSeC, so s6te)
Birt�pace ol Wtlrer (SUIe oe iaeqn wvntty) ���/J
(�IFUY maqen nartre al app4am's mourer --iSZ��'-�'N'�—�—
(11 aEOptatl. dst Rdopwa Peien6ONy)
Reskercs of mo�her (i� Eeceased, so state) �/�'
&Mplaca ol moNei (State or loreyn country) ���
ACKNOWIEDGMENT
I ackrowleUge Ihal I have receivetl intorma:ion regarding tlargerous canmuricaWe Eiseases
Ihal are sevualy larsrtiitleE, anG st ol Ihe tes sii Iw Ihe virus Ihat causes A� S( w
immune daliciemy syntlmme) '
SigreWre ot Apd�nl �- �O pata � � �
Tl�e above aDd[aM h25 objecled lo v¢nl�v�g Dy 02t� w attvmation w Syn3Nre lo Ne aCOVe The above appticaiv has objedetl lo v¢rdyu�g Oy oaN v aHimation or signacure to t�e aDwe
acknowletlgment Cecause ol retigious Cetieh. ackrawleEgment Decause ol retigious Cetieh. �
ClerkolCaun pale CkrkolGOUn Daro
State o1lMrere �.
Cainry of �
��
New REarea
1 I 5v.aar/aHVm W i tt�e iNOrtnaYOn given
.) u /n uJS e00�abn s mn artl corteG.
D✓
�+e 3
i ol me Gmson Girunt Coun
CONSENT OF PARENTS, PARENT, OR GUARDIAN
Wa, ine paren6 0l Nrs ap0��l �e�eCy give r.munt br ��s martiage. II oNy ma paren� sge¢,
slale Ia[ts wtYCll mdk! NB COn5Bn10i 1lIB 01l1e! OatBnl UnnBCB55dry
Stata ol InEera �
Goony al ) ss.
Faure� iD � .
Mo��ei ID � .
Smscripetl anp 6wpn �o Debra mB Ne _ Cdy 01
Gerk
56te ol Intlwia 1 I swearhlivm W� Ne intorrtelion 9^'an
CouniY ol-��, � ss. In tNS x00imtion ¢ Vue anE carrx�.
�,����V_ l�(�..� �v �,R-�-
New RNJeess L
SiOSCr arq sworn b fwe me Nis Eay ol ,�7/�
GbM1 al tM GESm CicW Coun
CONSENT OF PARENTS, PARENT, OR GUARD�AN
54e. Itie parmis ol Ilus apqianl. �eraEY 9rva consanl la Iltis martia9e. 11 oNy w�a pa�enl sgris.
stale facls whic� make Ihe consenl ol I�e oNer Oa�enl unnecessary
Stl�e ol IMgna �
s.
Fartier 10 � _
Mdtrer ID � _
SiCSCriEeE aM rwvrn b befo�e mo ttus - CaY ol .
Gbtk
COMPLETE IF MARRIAGE LICENSE ISSUED BY ORDER OF COURT. A marriage license having been refused to the above named parties, the
County Court, by written order issued
and filed in , auihorizes and directs ihe issuance o( a marriage license to ihe above named parties.
� RETURN OF AtARR1AGE LICEtiSE AhD b1ARRIAGE CERTIFICATE
�
/ cernfi�� rh�nt th�/r/,(eqwas fi[ed in my o�ce a marringe ficeuse iss/i A 6�y� thpe �C�(erA nof th�e Circuit Co�vr o/j�Gibmn Comuy. Indinnn.
dated��jL,y(.r.�C, %�3 . nuth i-ing the marriage of (,���J�LJ, G�`� eiD-L.l�a_1.�1� m�d
� �/.��f "� %�- - <'
l fii her certifi� tha� di/.Tb(lowb�g marringe ce�7ificnte was fi(ed iii iriy o� e: � .
/. ( ��� ,s.s�x- ��( irie), certi � that on �(date). nt in
����u�iry.'FhAinna. � �--�^_�! � oj � Counry.
epw (sraie). a�d :�<��/lv�Ln.a� oJ�y.�.�,.. Cawt��.
�,r (state) were married b}� me as nuthori�ed w�der a u�arriage ficei�se rhat was issued by the C(erk oJd�e
Circui! Co�o ojGibson Coun t l�iAinna, dated �� 9, %��
Signedbv:� �� �,_�� (o�cia(de.rignntian)
Filed and recorded n accordance wuh d�e lnws ojthe State ojlndiana oi� -3 (dnre).
Siq��ed �C4,.. "s,' �.I.�i.....,�8� Clrrk
, _ .. ., . ,.. � e