| 1. The full christian and surname of the man is: 2. Color:
 3. Where born:
 4. When born:
 5. Present residence:
 6. Present occupation:
 7. If no occupation, what means has the male contracting party to support a family?:
 8. Is the male contracting party of nearer blood kin to the female contracting party than second cousin?:
 9. Full christian and surname of father:
 10. His color:
 11. His birthplace:
 12. His occupation:
 13. His residence:
 14. Full christian and maiden name of mother:
 15. Her color:
 16. Her occupation:
 17. Her birthpalce:
 18. Her residence:
 19. Has the male contracting party been an inmate of any county asylum or home for indigent persons within the last five years?:
 20. If so, is he now able to support a family and likely to so continue?:
 21. Is this his first marriage?:
 22. If not, now often has he been married?:
 23. Has such prior marriage, or marriages, been dissolved?:
 24. If so, how?:
 25. When?:
 26. Is the male contracting party afflicted with epilepsy, tuberculosis, venereal, or any other contagious or transmissable disease?:
 27. Is he an imbecile, feeble-minded, idiotic or insane, or is he under guardianship as a person of unsound mind?:
 
 Signature of applicant
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State of Indiana, Shelby County, SS:
 deposes and says that  has personal knowledge of the facts above stated and that they and each of them are true.
 /s/
 Subscribed and sworn to before me, this   day of
 /s/
 Clerk Shelby Circuit Court.
 
 | 1. The full christian and surname of the woman is: 2. Color:
 3. Where born:
 4. When born:
 5. Present residence:
 6. Present occupation:
 7. Full christian and surname of father:
 8. His color:
 9. His birthplace:
 10. His occupation:
 11. His residence:
 12. Full christian and maiden name of mother:
 13. Her color:
 14. Her occupation:
 15. Her birthpalce:
 16. Her residence:
 17. Has the male contracting party been an inmate of any county asylum or home for indigent persons within the last five years?:
 18. Is this her first marriage?:
 19. If not, now often has she been married?:
 20. Has such prior marriage, or marriages, been dissolved?:
 21. If so, how and when?:
 22. Is the male contracting party afflicted with epilepsy, tuberculosis, venereal, or any other contagious or transmissable disease?:
 23. Is she an imbecile, feeble-minded, idiotic or insane, or is he under guardianship as a person of unsound mind?:
 
 
 
 
 Signature of applicant
 
 ----------
State of Indiana, Shelby County, SS:
 deposes and says that  has personal knowledge of the facts above stated and that they and each of them are true.
 /s/
 
 Subscribed and sworn to before me, this   day of
 /s/
 Clerk Shelby Circuit Court.
 
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