Marriage Certificate - Sparks, Holly R_5/13/2003b8 , , •-
Famv��,e.aey j�'I �'_ ��jJ STATE OF INDIANA No.
�,�.�� ti. �.r i�.J .L'�• •
dK�,-,.� APPLICATION FOR MARRIAGE LICENSE File
MAY 1� Z003 GIBSON COUNTY `�� ����
Dat A plication
IC 31 - 7-� 1. Fumishing�false�lnlom�at�on y/jion apptying for Ilcense.
A person w�o;knowingly;lumislies�lalse�infotmation to a clerk of the Female Applicant 50 > No .�� Ye5 ❑
circuit court vifien t6e peison applies'(or'a marriage license under IC If No, Medical Exa ination or Report D t d
31 � 7- 3 commits a Class D felony. - NamO of Physician
MALE APPLICANT � FEMALE APPLICANT
Name }� \(� w A.FiCsl C� MiqEle
47MJ\J\]�.xY� .
Daie ol Bvin MonN I — 1U Da� /_ Yea�
Race ol BirU (Spb or taebn muntry) �
R.: ence nEOres Sveet �•AR y �nry St Ie
'� � '�mr ito91�' t�° ..0,� �SlJ �{7634
Revbus Mariul Sbws: Neve� MartiedyiiR No. ol Provious Marrgges
Lest Martiage EMeE BY: �2dN ❑ DivorcO p MnNrtCnl ❑ Data
Dd4 0� Ev�� venfie0 �y: O&rtn GeNlira�e o ONer (SpecYy)
1. RI! YOV �qw Of h]M yOV !Mf p2Bn dEp1.1gM 10 bB 01 YnSqVM mM? fy>�Yes O
Ilenawviizyes,-tvsMeapjWcalbnbeen�emoveCi No0 Yes❑
2. Rr0 yW �ela�l0 b 0i! Ilr.ele eppfranl CbStt Ndn SBCpM cousln? N��Yes ❑
J. R�e yo� now untler Ne'uJNerce ol en akohofc peverage? N:.�� Ves ❑
� �. Ree yo� now unGe� Ne Wluence al a re�wl� Eeug? N�3� Yes O
es. Lai lne tu8 �umez ol a�r/ aeperoent cnJaren.
u]
U
2
Z
a 6. (a) FNI iuma ol appBCan�'s lather (� __
Q III ampied. 5si aeoo�e Pments ony) �U Vt$ _
a Rettlence ol hYie� (II Oecea , so slale)
BnNphce ol tatMr (Stata o� Iwegn country�
(o1FUArtgiEenremealapp�icanfsmo�ne.(7� �.�_ —n
(II aOOpbC, fsl REOptive Parents ONy) LS.�/�� QCi'L.
Resitlenc8 0l mONer (J Eeceam0, fo sidl9) \ V J
Birinolau oi motner (Spm or iweyn muno-y)
Name � \ � (\ ��st , �p Mqtlla ' ^ � L�
'f"\\]aCjl.�4c ?\ �a
Dale ol BiM A._. Ih I� Year —
Ppce o1 &M (Sra�e or Ioregn counvy) p _ __' n^
tJ�A`QMi]/\Jl 1[ V O
Resitle nd aw $trPe _ Ciry Goun $taie '
33�i �, �,. �. . w`k+ . '�l1 a rtMe�Y+
P�eviwsMadtalS�aWS: _meMartiay��R No.ofRevbusMartuges
Last Marriage ErMetl By: DeaN ❑ Divarce ❑ Amulment ❑ Dale
Da:e o1 o'vNveeJiee Cy O 9eN Cehtliata ❑ ONet (Spen'ly)
t. nee yvv row o� nave you eve� Deen ae'ryaged m ee ol unw�nc �n'M? No � Yes ❑
II amwer b yes; tws Ne eEryCicaUOn �een removeE? No�r Yes ❑
2. Ne you related b Ne �4 ap0��� cbser Nan semnE cousin? No p Yes O
J. nre you row uMe� ure inflcence ol an akotalk EeverageP N-'C'— Yas ❑
a. Aro yvu row urWet Ine NlluprcR ol e narcoCC Cetq? N�� Yes ❑
5. l'¢I Ne Iu0 remes ol any tlepenCant chiltlrtn.
6. (a) Fu0 name ol apD����'s IaNer
p� atloo�e0. 4st nEOp;ive Parents OnN)
<
Resbeze o� IaNer (il CeceauE, w slale)'�
BWiplace o1 la•Mr (SU:e o� lo�eyn wun•.ry)
(b�FVll mailen name ol ao0��� s rtatM1ei�
(II atlaptetl. 45t Mop4ve Paranis Only)
ResWer¢e ol mot�er (il Oeceas E. =o �. e) �
8'vihpaca ol mo;tier (Siate o� Iwelgn co�nYy
ACKNOWLEDGMENT ACKNOWIEDGMENT
I xknoxledge Uu� I have receiv¢d inbrmation regartling dangerous commurJCa�le tliseases I ac'RravAeEge that I lave receiveE information regaraieg <
Vu1 are se•w0y trartm'vKetl. . a tisl ol Ne test vtes lor �e wus thai causes AIDS (acp�iretl Ret are sezualy Uansrrvtted, a � li�f 1 me te y-1es tor P
munune eeloency syMranel ��//� -- `_�/'n/ immune tleficie s ro.^ie� y // { �// //J,,(�,(�"�
^ry Y� �L��C��i��� /
9greWre ol Ppplkant w"� Da;e � SgnaWre ot Appliwm
TM above apd��� M1�5 O�jecleE to veritying by oalh w atiumalion Or sgna:ur_ to Ihe abpve
acknowleCgment pecause of reGgio�s petie:s.
Gbek o� Coun Daie
9a1e ol Intluiu � I sx¢adallvm �hat Ne'uJarmauon qiven
Cauny ol _ � ss. n Ws apptiration is true ark mrtttt.
Sipnee
New PGOrea �
sworn b De�e me
GiDSOn GrcWl Gove
CONSENT OF PAqENTS. PARENT, OR GUARDIAN
We, Me pemnn ol Nis epplFant, �ewCy give m�em Iw Iha martuge. �I oNy one Oamnl sgns.
Slele lac�s rTC�I mdke Vle fAnS<n� ol 111e olllet pdren� Vrviecessary
SialeollnGUru )
Caunry a� ) ss.
Fat�er ID + _
Molner ID � _
SuOUri�eC aM swm b Eelore me IM1a _ Cay ol ,
Gmk
v.
ommurucaEle diseases
kauses AIDS (acawetl
Da�e , —5 y o/
The aCOVe applicant tas objectetl to verilying by oat� or allirmation or sigreWre b Ihe above
ackrqwle0gmenl because ol rel"m�iovs �eliets.
Cle�k o� Coutl pa�e
Slaro ol IMana � I sweae/alfum WI Ne'vuama�on given
GouNyol � ,�,a_) , u� HWSapp6�J�nr.yueandmrrxL
AEtlresS L
J
� b �o�e me
ol tna Gasm Cecvii Court
CONSENT OF PARENTS, PARENT, OR GUARDIAN _
We, Ne �rems al �his a0q��t �ereCy give consem Iw Na rtvrtiage. II oNy one parent spns.
s�a�e lat�s w�kp r,wk0 t�e consen� ol Ne oNer parent v:mecessary
Spteoll`Miana j
Govnryol ) ss.
FaNe� ID � _
MoNe� ID � _
Su�.,crl�ed anE swarn b Delore me ihis _ Cay ol ,
Glrk
COMPLETE IF MARRIAGE LICENSE ISSUED BY ORDER OF COURT. A martiage license having been refused to ihe above named parties, ihe
County Court, by written order issued
and filed in , authorizes and directs the issuance of a marriage license to the above named parties.
RETURN OF MARRIAGE LICENSE AND D9ARRIAGE CERT[FICATE
I certifi• dmr there wns fi(ed ir� my ojfice m m�rringe license issued by tl C(erk oJ rlte Circuit Co�vt ojGibsoii Counpt l�idiana.
dnted � / , author,1i;,i��g die umrringe of � and
�L� i� 0 . . �/ 4 . _ /� J
I fi�der certify
„�as fi�ed rn n,r� off �e: � a�
I. certi(}� 7har o�t
at ii�
�(smre). and j� �o��._y�i-yi oJ -�-+�(rwr/`' Counrp.
(smte) were mnrried � me ns nuthori�ed under a marriage licertse thnr roas issued by die Clerk oJdie
Circui( Courr jGibson Counn /n ia�m, nted '�-� / ,
Signed by: - - • • — (o � •ial destgnatian)
Fi(ed nnd recor d in nccordance �ohh rhe [nrvs of the Smte of b�dia�ui on _` . ��� (date). ,
SignedY"-'.�"" " -"� Clerk
GiGson Circuit Courr
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