Fill and Sign the All Material Appearing in This Repai is in the Public Domain and Form

Vital Statistics Form Revised February 2011 Page 1 of 1 V I T AL ST AT I ST I CS FO R M St a t e o f W y o m i n g D e p a r t m e n t o f H e a l t h A BSO LU T E D I V O R CE O R A N N U LM EN T STATE FI LE NUMBER _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1 . HUSBAND ’S NAME ( Fi r st , Mi d d l e, Last ) 2 a. RESI D ENCE -CI TY, TOWN, OR LOCATI ON 2 b . COUNTY 2 c. STATE Bi r t h p l a ce ( St a t e o r Fo r e i g n Co u n t r y ) 4 . D ATE OF BI RTH ( Mo n t h , Da y , Ye a r ) 5 a. WI FE’S NAME ( Fi r st , Mi d d l e, Last ) 5 b . MAI D EN SURNAME 6 a. RESI D ENCE -CI TY, TOWN, OR LOCATI ON 6 b . COUNTY 6 c. STATE 7 . BI RTHPLACE ( St a t e o r Fo r e i g n Co u n t r y ) 8 . D ATE OF BI RTH ( Mo n t h , Da y , Ye a r ) 9 a. PLACE OF THI S MARRI AGE -CI TY TOWN, OR LOCATI ON 9 b . COUNTY 9 c. STATE OR FOREI GN COUNTRY 1 0 . D ATE OF THI S MARRI AGE ( Mon t h , Day , Year ) 1 1 . D ATE COUPLE LAST RESI D ED I N SAME HOUSEHOLD ( Mo n t h , Da y , Ye a r ) 1 2 . NUMBER OF CHI LD REN UND ER 1 8 I N THI S HOUSEHOLD AS OF THE D ATE I N I TEM 1 1 Nu m b er _ _ _ _ _ No n e 1 3 . PLAI NTI FF/ PETI TI ONER Hu sb an d Wi f e Bo t h Ot h e r ( Sp eci f y ) 1 4 a. NAME OF PLAI NTI FF/PETI TI ONER’S ATTORNEY - - - - - - - - - - - - - - - - D O NOT FI LL OUT BELOW THI S LI NE 1 4 b . AD D RESS ( St r e e t a n d Nu m b e r o r Ru r a l Ro u t e Nu m b e r , Ci t y o r Tow n , St at e, Z i p Cod e) 1 5 . I CER T I F Y T H A T T H E M A R R I A GE O F T H E ABO V E N AM ED P ERSO N S W AS D I SSO LV ED O N : ( M o n t h , D a y , Y e a r ) 1 6 . T Y P E O F D ECR EE -D i v o r ce o r A n n u l m e n t ( S p e ci f y ) 1 7 . D AT E RECO RD ED ( M o n t h , D a y , Y e a r ) _ 1 8 . N U M BER O F CH I LD REN U N D ER 1 8 W H O SE P H Y SI CA L CU ST O D Y W AS AW ARD ED T O : H u sb a n d W if e Jo i n t ( H u sb a n d / W i f e ) O t h e r N o Ch i l d r e n 1 9 . CO U N T Y O F D ECREE 2 0 . T I T LE O F CO U R T 2 1 . SI GN AT U RE O F CERT I FY I N G O FFI CI AL 2 2 . T I T LE O F CER T I F Y I N G O FFI CI AL 2 3 . D AT E SI GN ED ( M o n t h , D a y , Y e a r )