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County of Douglas, State of Nevada APPLICATION FOR A CERTIFICATE OF AUTHORITY TO SOLEMNIZE MARRIAGES IN THE STATE OF NEVADA 1. Full Name of Applicant Nickname or Alias used 2. Residence Address City
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Nevada SOLEMNIZE deposes ISSUANCE ordination foregoing repayment applicable SUBSCRIBED enforcing pursuant Applicant Notary UNLAWFUL affiliated specify therein compliance thereof revoked Mailing duly incorporated

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