Per KRS 402.100(1)(c) the form shall provide for the entering of "The date and place the license is issued, and the signature of the county clerk or deputy clerk issuing the license."
Exhibited below is a properly filled marriage license. If you can not view the image then please see Exhibit A in this pdf: https://www.liberty.edu/media/9980/attachments/2015/080515_Complaint_-_Davis_Third_Party_Complaint_against_Gov_Beshear_FINAL.pdf
The date issued is "6/16/2015", the place issued is "in the office of KIM DAVIS, ROWAN COUNTY County Clerk, MOREHEAD, Kentucky", and the signature of the county clerk or deputy clerk issuing the license is "BRIAN MASON, DEPUTY CLERK"
As I've specifically posted “references to Rowan County and her clerk’s office” have been removed. Since you are unable to determine what is left on the form I will again go out of my way to help you. Removing “references to Rowan County and her clerk’s office” leaves the date and the signature of the county clerk of deputy clerk issuing the license.