Marriage Certificate - Wilhite, Angela L_6/3/2003�' � � 91
� �e,a • STATE OF INDIANA� � �� � No. �
-""°'"°°"' APPLICATION FOR MARRIAi.rc LICENSE File
d��,.�.�
_ GIBSON COUNTY \ \ \ 6-/-O/
Date o App ication
IC 31 - 7- 9- 1: Fumishtng lalse I�ormatlo� upon applying tor Ikense. � Female Applicani 50 > No�O Yes O
A person who knowingly fumishes �alse Informatlon to a clerk of the � .�'3/—Q�
circult court when the person eppiles for a marrlage Ilcense under IC If No, Medical ExBminalion or RepOrt Dated
s� - �- 3 commus a Ciass o teiony. Name of Physician
MALE
FEMALE APPLICANT
�� o� a�, ��� �Y/ 8 �ae,s� �„ o, � v Mi7J ��/ v�%
Place ol Bbin (50b a bre4^ counbf') T/'/ Pbce ol 81rm (Sram w Iweqn m�mvy) T//
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lar �7(.O_O. t7�J �� f�,' �L
Pnvbu� arlml ,: Nwsr 0 OR No. ol Prevlout Alarthp�f R�vlou� Manmri aotu�: N�wr A1e - � OR No. ol Revbu� Marrlapu
lest A1a^hP EtMBd �^ OeaOi o dWrq� MrNmBnl ❑ Deb � Lest Mazefaye Entlea 9y. OBiVi ❑ Dhpte� PrvMment O Dala I- �
OaID d dM ve�ISetl Dy. ❑ 0�M Ce�4�Fate �We� (SGe��Y) Dato ol Wih vmtlbE �y: O BFN CeNlkab �ihier (SbeqN)
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Aee yov fmr a Aava you ever Oeon eQ�1peC b Ee W unsounE rtbtli
II enrrer k l�'+: las Ce eCh�etlon Oeen �a�mveE?
Aro you relateE b Iha k�b ew4'aN cbstt Oon ceconE mu4n'!
Rro you now wder tM WhrencB OI Bn eYNUC Ceva�age?
Rre yau emr unEer IM WNerca ol e rermtk Mqi
LM �M�ND e¢ire5i1 aM 4ape�tleM cMtlren.
(II eOapbC. Rst /.UapOVa Pei I5 QYy) l.1 ^
R latl�r(Iltlace sed.mctate) �
& Sqre o� �o qn wmoyl .
11115 61110NT
tlop optive Pe nts OM'1
mome� l'u o . w aa�el -
oi rtqthar (Slare t lueipn mm%)
No CX Yes O
No ❑ Ves ❑
No� YM❑
No �" Yes ❑
No� Yes ❑
ACKNOWLEDGMENT
I ackroMedge Ihat I have rece' e in7artnaGm regartlirg dangerrna wmmurtinWe diseases
Na� are uz�aly Vartmrtle0. a 451 d Cre Iat yte 1 ihe wus that n� AIDS (acQ�rired
arvnw,e eefrierc.r e) w. L_�-1
Sigrrature ol Appfirant� Date
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ae yw mw a leve you evee Caen etladpaC b De ol unwuM mW?
II Brtwer b'/n. !ms Eie aaWicetbn Dee� �ertove0?
Ne yav eelateC b IM �b appWanl cbstt Iten semiE cousN?
Na you now wder IM infirorca ol en akolqFC Ocvaeage?
Are yoU nOw Nqlr NB 4illue�t0 018 rercaY[ Nuq?
L$t IM lul �ert�@TOl aery tlepp�Ment tldQ�en.T_
e. lal -__.ama a w
pieaoo�ea.ov
sbte)
No'R' Yes ❑
No ❑ Y!5 O
No� Yes❑
Ne,E' Yes ❑
N� Yes O
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see. so stare, y
bregn montry) _��
ACKNOYlLEDGMENi
I ackroMetlge that I hava receive0 iNwmation reprdrg tlangerms cammuricade tliseases
U6I3f8 SEXIRM ���m«�� a� a�� OI �hP fP s! iw Ne Wrus IM1at W �ses A� ( WweE
immune tlefidency syrdr �1e �
$Ign2M@ ol AppIk2M �
The a0ove applirant has�eded lo verltyhig Cy mth v aXirrtation a signatwe to Ihe above I The above appicaN Ms oGjecled to verliy'vg Ey oaN w alfirmation w sg�atura lo Itie aDOVe
ecknowled�neM W retigious be6th. �� acknovAedgmeN Decause W rBligipug Oe��e�s.
Cle�k ol Cowt � Data � C�eik ot Cou�t g1e
State d INiana 1 I sr.�rlan"vm tlet Na 4�brmaEOn 9Wen
Coun7 0l 1 ss. ti mk eGV�mum'a u�w entl mnect.
�,�,�j'—�cJ�.�
New MCrea
Grtwta'M eM sxem lo Celrne me t�k�OaY ol .� �g
ol Ne GiCwn Circuil Gouh
CONSENT OF PAFENTS, PARENT, O UARDIAN
wa. ttn Oarana ol Nk eC��m. nereCY BNa mersent Iw �h's mal�la9�. �I onN me Garent sigre.
sta�e hcls whk� mako Ne mnsent ol l�e ot�er pamnt unnecessary
s�a�e a ��are 1
r...�..wn� 1 65.
FaRier �'
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�beE en0 awn� b Eebre me Nk _ OaY ol
G�e�k
Spu ol InCfare � i sveana�wm ma� ert nwenevon yrve�
Counry ol 1 s in tltl5 appimwn 6 true antl mrtect
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New RENess —
SWSC�1�eEeMSpnrhmDalaqryeNis� ¢]yol f' ��/
oi Ne GMOn Ghcun Gcurt
CONSENT OF PARENiS. PARENT, OR GUARDIAN
We. I�e parenis ol Ns eppYanl. �eieEy gNe conunl la Ws marruga. 11 orJy ore paienl sigia.
slate lacls w�k� m0ke t�s w�senl ol I�e all�er pa�anl unnecessary
Spie ol InC1a'a 1
r ...v M . 1 55.
$iD5aNe0 ard sv.'an b Ootme me Nh — CaY a
io.
ID �
Ck�k
COMPLETE IF MARRIAGE LICENSE ISSUED BY ORDER OF COURT. A marriage license having been refused to the above named parties, the
County CouA, by written order issued
and tiled in , authorizes and directs the issuance of a marriage license to the above named parties.
RETURN OF 111ARR1AGE LICENSE ANU MARRIAGE CERTIFICATE
I cernfv
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d�ere was filed in me o�ce a mnrringe license iss� ed he rhe Clerk oJd�te� C��irc�u�it Cnurt njGi6.con Ca�utr. lnAim�a.
��D_U_I—. nuthori;.ing lte m ringe nf���' ��t�
i �
cerriJicare ��•n.NfileA in ��rr
_(npme). cerrijv rhnr
�0 —aW �— (dnte). o� �e1.�'"in
C7. �j .�^_t%�'.J Crnmtc.
��' As4nhJ Cnunh•.
v!Fl�� (s(nte) «•ere mnrrieAbe me ns nutltnriceA under n�narriage license dmt ��•ns issued be the Clerk ojdre
Circui� Coi r njGi on i��, InA� nn. nted�� a� � �
Sigiiedhy:�k�L� - — - Qf�nff�ir�.�inldnsi,enarianl
Filed and recorded in nccordmice �vith die Inx�s oJdie Smte of InAia�m on __.,�4�/�`v /�'�-�'ri �(�me).
v ����/ � �J�
, ` ' SigneA_�t�!�`'�� "�'^'�Gerk
Gi6.cnn Circuit Courr
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