Marriage Certificate - Folsom, Bonnie F_8/6/2018 STATE OF INDIANA 551
w P � APPLICATION FOR MARRIAGE LICENSE No-
: Fibed
emhw state Board of File
Heat under rumor% GIBSON COUNTY c y'oc,
d C 31.7-3
IC 31 -7-9-1.Furnishing false Information upon applying for license. Date of Application
A person who knowingly furnishes false information to a clerk of the Female Applicant 50> No l7 Yes
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 APPLICANT
Name , Fi.• M'? r t Name /•(� Frst /�gNe la
. tar lam_ •4'�e •� / .T LC.i�i6�'CJ
Date of Birth ! .n �• Day [e` Year Date of Bit Infix Y .y
Place of Birth( or loregn county) / 1e Place of Birtghb to or foreign country)
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Res �rea�I SJ •or Retry.,'spry ! R6fF�/ dregs„ Sµ/JJY Cou�„�$I�pe _ / t
Previous Marital Sans: Never Married OR NNo:of Previous Manages Previous Marital Status: Never Married❑ OR No. ff Previous Marriages 4
Last damage Ended By: Death 0 Divorce 0 Annulment 0 Date Last Marriage Ended By: Death 0 Divorce)( Annulment 0 Date Si 7 y
Date of birth verified by: GD Binh Certificate 2 Other(Specify) Date of birth verified by: D Birth Certificate 1p Other(Specity) !!
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I. Are you now or have you ever been adjudged to be of unsound mid? NoX Yes 0 1. Are you now or have you ever been adjudged to be of unsound mind? Nok Yes O
If answer is yes;has the adjudication been removed? No 0 Yes D II answer is yes,'has the adjudication been removed? No 0 Yes 0
2. Are you reared to the female applicant closer than second cousin? No1( Yes 0 2. Are you related to the male applicant closer than second cousin? Noy Yes D
3. Are you now under the influence of an alcoholic beverage? No• Yes 0 3. Are you now under the influence of an alcoholic beverage? No re' Yes❑ •
OJ ro
4. Are you w under the influence of a narcotic drug? No Yes D A. Are you now under the influence of a narcotic drug? NS‹. Yes D
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i? 5. Lir"-CO,um.M.nv med.thentchelds en. 5. List the as names of ny dependent childrenn
B. (a)Full name of applicant's father
f 6. (a)Full name of applicant's Per
0 (11 adopted.1st Adoptive Parents Only) 11 adopted,list Adoptive Parents ONyagea�ai i4fe(�
a
Residence of father(if deceased,m sacs) Residence of father(if deceased,so sea) I
a
Birthplace of ather State or foreign gn man I Alt Birthplace of father(Sate or foreign county)
(b)Fut maiden name of applicant's mother (b)Full((b)Full maiden name of applicants mother
(If adopted.list Adoothe Parents Only)- /' _• (II adopted.List Adoptive Parents OflM np
Retdence of mother(it deceased.so sate) Residence of mother(it deceased.so ate) y � �
Birthplace of mother(State or foreign country) �'a Birthplace of mother(State or foreign county)�yv
ACKNOWLEDGMENT ACKNOWLEDGMENT
I acknowledge that I have received information regarding dangerous communicable diseases I acknowledge that I have received information regarding dangerous communicable diseases
that are sexually transmitted,and gist of the test sit or the virus that causes AID (a ed that are seaualy transmit: nd a Est of th s tor the virus that causes AI ace red
immune deficiency syndromac �p� immune defciecy D S{� OG
Signature of Applicant Q .a(1 �W'OYt� Date. l b Signature of Apatica,F )C�dShc! Date�I
n The above applicant has objected to verifying oath or affirmation or signature to the above The above applicant
pW I hMng fry g tet be has objected to via fiefs. by oath or affirmation or signature to the above
acknowledgment because of religious beliefs. acknowledgment because of religious beliefs.
Clerk of Court Data Clerk of Court Date
State of Indiana ) I swearatlm that the Information given State of Indiana ) I swear/atfum that the Information given
County of ) ss. In this application is true and correct. County of J in this application is true and correct.
New Address New Address
Su d lied y�pr •me day ot_Lp., �QQ C Subscribed and • to•,the me vis.day o . 0
J oClerk of the Gibson Circuit Court '11w a 9• Clerk of the Gibson GrMT Court
CONSENT OF PARENTS,PARENT,OR GUARDIAN CONSENT OF PARENTS,PARENT.OR GUARDIAN
We,the parents of t is apol ant,hereby give consent for this marriage.II only one parent signs, We,the parents of this applicant,hereby give consent tor this marriage.It only one parent signs,
sate facts which make the consent of the other oarent unnecessary state facts which make the consent of the other parent unnecessary
State of Indiana ) State of Indiana )
County of . ) ss. County of ) as.
Father ID• Father ID•
Mother ID• Mother ID•
Subscribed and sworn to before me this day of Subscribed and sworn to before me this 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 MARRIAGE LICENSE AND MARRIAGE CERTIFICATE
I I certi , that there was fled in my ofce a marriage license issued by the Clerk of the Circcuit C urt of Gibson County, Indiana.
dated 7 U . authorizing the marriage of /T and
I f er cent hat uhf jol wing marriage certificate was filed in my o e:
i+ 9�y / �� ' ame), certify that on ' P-BO 6 (date), at in
�/I..4.60 `) County, Indian.. .1 - .• of 7v�•� County,
i g
p � (state), and .� • - Ara......--.....
— - of w-r(raayt+ County:
�"a. (state) were marrie by me as authorized under a marriage license that was issued by the Clerk of the
Circuit Cot ofGibso Conn In tame, dated ` le ,P.-QOM`
Signed by (official designation)
Filed and recorded in accordance with the laws of the State of Indiana on f a 4 (date).
c;)0 t - 13 -401-000• g6.8 -0 ato Signed Ei9ifii4 s•ul' " Clerk
a b' t8-II - 401- bbl• (9 a3- 004) - Gibson Circuit Court
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