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

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

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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 )

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How to Sign a PDF Using Google Chrome How to Sign a PDF Using Google Chrome

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