Marriage Certificate - Ferguson, Debra_5/3/2003 479
FannPrescnbed By STATE OF INDIANA No.
bid=Stale Bind or
Heath snow"°°"
atoi-i APPLICATION FOR MARRIAGE LICENSE File __
O3
am)
GIBSON COUNTY te of Application
IC 31 -7-9-1.Furnishing false information upon applying for license. •
A person who knowingly furnishes false information to a clerk of the Female Applicant 50> No ❑ Yes El?".
circuit court when the person applies for a marriage license under IC If No, Medical Examination or Report Dated
31 - 7- 3 commits a Class D felony. Name of Physician
MALE APPLICANT .. FEMALE APPLICA T
Name fe Ica I. Maid •E ' \ti Name ``:iv T. ...idle 7+n/
Date of Birth 1 • t• # •y % Year Date of Binh 1 anth I %r
_ I rr°�. I o 1 \ IPA,
�1 P=.111'j�ipl -or •e G c ,r tiff *; ..Ab�"a•_ 1 a tryt I
-�r :A ass 1 SLe•`� Coo) t,Fail„ Re 1JaYC&e tA��i 1-‘6 1� •uny
...--J Previous Marital Status: Never Married D OR NT;of Previous Marriages ) Previous Marital Status: Never Married 0 OR No.of Previous Marrag �J r_
Last Marriage Ended By: Death 0 Divo``rc�,eX Annulment O Date acc3_ Last Marriage Ended By: Death 0 OivorceY Annulment 0 Date `q9_W_
Date of firth vented by: 0 Birth Cemfiate *err(Specify) 0 Dare of birth verified or o Bich Certificate mbar(Speaty)
1. Are you now or have you ever been adjudged to be of unsound mind? NoX Yes o I. Are you now or have you ever been adjudged to be of unsound mind? NdX, Yes 0
If answer is'yes;has the adjudication been removed? No 0 Yes o II answer is"yes,'has the adjudication been removed? No 0 Yes 0
2. Are you related to the temale applicant closer than second cousin? No Yes D 2. Are you related to the male applicant closer than second cousin? NCg.�,�• Yes 0
3. Are you raw under the influence of an alcoholic beverage? No Yes a 3. Are you now under the influence of an alcoholic beverage? No Yes 0
co h
4. Are you now under the influence of a narcotic drug? N Yes G 4. Are you now under e Influence of a narcotic drug? Nrrr'"���/// Yes 0
c" 5. st the lull names of an •• -. -n r children. \ 5. List the lull names of any dependent children.
0 ,I 1�.. a A`"••-• \ •\ d._
z r •� `0 • /�
Er- 6. (a)FW name._1 applicant's lobar , (\(L_.�� � 6. (a)FUtl rams of applicant's when (1 1 I ) , ._ . ' 14(6 2
u II adopted,test Mohave Parents 01:4yZ Il ed red,listA We Parents0 IFYA/ /`a`�i
I- ( W p Only)_ a c ( W drip Only)
4 Residence of lather(il deceased,so state)—+' .^Q1'•`` Residence of Lather N deceased,so state) �•\+,%- ��
Birthplace of father(State or loregn country) `x_V - Birthplace of father(State or loregn country)
(blare maiden name of applicant's mother � .c 1`(�(\ !\ I,'�)r?\t\ Q Ibl(If maiden name of applicants rm = % a ,. , 11 ,
pt adopted,list Adoptive Parents Only) W-"�•N,�1)rl(\MAJ]Lr W l l r i (II adopted,list Adopwe Parents Only) / IJV;�;:�a I i
Residence of mother(Y deceased,to sate) `' Residence of mother(if deceased,so state)
Birthplace of mother(State or foreign country) S-C Birthplace of mother(State or foreign country) 1
ACKNOWLEDGMENT ACKNOWLEDGMENT ��tltl
I ackro that n
wledge at I have received intonation regarding dangerous communicable diseases I acknowledge that I Have re wed inform re cling dangerous conmuricabl seas
'•'-' that are sexually transmitted, a Est at the I `ices for the virus that n AIDS(acquired that are sexually tyansm'te t/I h t' tor,the virus that • e(vr{d(a,.atr
immune deficiency sypyom€f /�(�,�� ;/ immune deficiency sy 0 e) r LI .. C) 03
Signature of Applicant ((( • rL. Da a Signature of Applicant Dat
`J The above applicant has objected to ventying by oath or affirmation or signature to the above The above applicant has objected to verifying a oath or allirmation or signature to the above
acknowledgment bemuse of religious beliefs. acknowledgment because of religious beliefs.
Clerk of Court A� Date Clerk of Court - Dare
Sate off \ -)(5) ) I swearlsffirm that he information given State of lndara- 1', ) I sir-.rhfM1rm hat the 6rlonretnn given
County ol_ J J ` ) ss. In this application is true and correct. County of _�� ) `� this e�dpYCacon s true and carat.
/// ' y...._,,�[7 q ,/ i / C
Sgne _C.l�-4 7-(d� Sig4'•l J ' %X A
New Address - - —,tr�•-r}
5 a s,'ent • rtre+Y� `...•� _ ,��3 5 rib:.• b day• P. w 1 rv-J( T\__7
Y iTfT1
� L _ • �14` ) 'A\ Jerk of the Gibson Circuit Court 1 y `f .L CS TA Cleat of he Gasao Circuit Court
CONSENT OF PARENTS.PARENT.OR GUARDIAN' CONSENT OF PARENTS,PARENT,OR GU'DIAN
We,the parents of this applicant,hereby give consent for this marriage.II only one parent signs, We,the parents of this applicant,hereby give consent for this marriage.It only one parent signs,
state facts which make the consent of the other parent unnecessary stale facts which make the consent of the other parent unnecessary
State of Indiana ) Sate of Indiana )
County of ) ss. • County of ) ss
Father ID• Father ID*
Mother ID• Mother ID•
Subscribed and sworn to before me this day of Stnscribed and swum to before me the day of
Clerk Clerk
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 _ ,authorizes and directs the issuance of a marriage license to the above named parties.
.�
RETURN OF NIARRIAGE,LICENSE AND MARRIAGE CERTIFICATE
/ certify laat thy�-if was filed tin my office a marriage license issue — the ark of the irct it Court of Gibson County. Indiana,
dated__ !Is•}��l"�O „iota authorizing the marriage of _ .7 and
faiirtF ••?F -rt-r-
I " ate ce .ft t/at •following marriage certificate was filed in my offic
Lemma _•' (r t(�/yyyy' ca�r{ify that on z .�(rinte), nt_,� "�'�' in
it I
k � .
� •• County.lnrlinnn,—=-p-� 2 — - - of `<!�v County.
(state).and Zatt a.._.7 _ of— _ County.
. • (state)were married by me author'-ed under a marriage license that was issued by the Clerk of the
Circuit Cat t j Gibs n gtry._l(ulinNa',dated _ -3 Q_�'?U.3 -
Signed by ��'!-�% �——;/=v_ (official designation) .
Filed and recorded in accordance with the laws of the State of Indiana on GUj_9 r}003 ((date)
Signed "-s. Clerk
ranrnrr r'irr,rir Cnurr a