Marriage Certificate - Morehead, Stephanie M_3/17/2014 - Form prescribed by Indiana State of Indiana No. 2007-65
State Department of Health
Under Authority of Application For Marriage License Application Date: 11/30/2007
IC 31-111-4
Gibson County Expiration Date: 1/29/2008
Male Applicant Female Applicant
Name DANIEL A MOREHEAD Name STEPHANIE M ZILIAK
Age 27 Age 23
Residence 114 S EILEEN ST Residence RR1 BOX 353 C
•
HAUBSTADT,Indiana 47639,USA HAUBSTADT,Indiana 47639,USA
County of Residence Gibson County of Residence Gibson
Birth Place West Virginia.USA Birth Place Indiana,USA •
Dependant Children Dependant Children
Father's Name WALTER D MOREHEAD Father's Name JOSEPH W ZILIAK
Father's Residence Father's Residence
Illinois.USA Indiana,USA
Birth Place of Father Ohio.USA Birth Place of Father Indiana.USA
Mother's Name DEBRA L WEBB Mother's Name KAREN M ZILIAK
Mother's Maiden Name KORAN Mother's Maiden Name BAEHL
- Mother's Residence Mother's Residence ,
_. Ohio.USA Indiana,USA
Birth Place of Mother Ohio,USA Birth Place of Mother Indiana.USA
Consent of Parent(s) or Guardian Pt applicant is under 16) Consent of Parent(s)or Guardian (If applicant is under 18)
I (we), the parent(s) or guardian(s) of this applicant, hereby give I(we),the parent(s)or guardian(s)of this applicant,hereby.give consent
consent for this marriage. (if only one parent signs. state facts which for this marriage.(if only one parent signs,slate facts which make consent
make consent of the other parent unnecessary) of the other parent unnecessary)
Parent/Guardian Parent/Guardian Parent/Guardian Parent/Guardian
ACWledg ents I acknowledge that I have received information regarding dangerous communicable diseases that are sexually
transmitted and a list of the test sites for the\virus/J}c,ness AI (acquired�/u//n�/ej/deficien sy mnd/r me)
\/�/��, ,// /J—C lv�f cant S. /fir �/r/
/$i�I•atdraapplicant �7/ / /Signature applicant ,/
❑The above applicant has objected to verifying by oath or affirmation or ❑The above applicant has object to Eying by oath or affirmation or
signature to the above acknowledgment because of religious beliefs. signature to the above acknowl nt because of religious beliefs.
Affirmation 1 swear/aRrm that the inforn)�dlon provided orally and in writing in this application is true and correct and have been advised of the
C following:IC 316ll- 1.1.Fahe information in marriage license application der IC n who knowingly furnishes false information to a
Clerk of the Circuit Court when the person applies for roam a lit ;Under IC -111 commits a Class D felony.
ignature of applicant Signature a a licant
There were no legal Impediments to the proposed marriage discovered by the clerk based on information provi either applicant
$.•• ribed an•sworn to •-f. -me th. :Oth day of November,2007 So•r :bed and •m to before - this 30th •f November,2007
CI-rk of the Gibson • ty Circuit ou . Clerk o the Gibson Count Circuit Court
MLe: 2007-65
ac— I s-3 (- yp y- 000 . 132 - 009