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.
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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
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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.
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