Fill and Sign the Divorce When a Spouse is Pregnanttexaslawhelporg Providing Form

LOCAL INDEX NUMBERSTATE FILE NUMBER New York State Department of Health TYPE , OR PRINT INP ERMANENT BLACK INK CERTIFICATE OF DISSOLUTION OF MARRIAGE 1C. SOCIAL SECURITY NUMBER 2A. DATE OF BIRTH 2B. STATE OF BIRTH 4A. RESIDENCE: STATE 4B. COUNTY 4C. LOCALITY (CHECK ONE AND SPECIFY) (COUNTRY IF NOT USA) CITY OF TOWN OF VILLAGE OF 4E. IF CITY OR VILLAGE, IS RESIDENCE WITHIN CITY OR VILLAGE LIMITS? 4D. STREET AND NUMBER OF RESIDENCE (INCLUDE ZIP CODE) YES NO 4 IF NO, SPECIFY TOWN: Wife/Husband/Spouse5A. ATTORNEY - NAME5B. ADDRESS (INCLUDE ZIP CODE) 6A. NAME: FIRST MIDDLE LAST 6B. BIRTH NAME, IF DIFFERENT 6C. SOCIAL SECURITY NUMBER 9 9D. STREET AND NUMBER OF RESIDENCE (INCLUDE ZIP CODE) 9E. IF CITY OR VILLAGE, IS RESIDENCE WITHIN CITY OR VILLAGE LIMITS? YES NO IF NO, SPECIFY TOWN: 10B. ADDRESS (INCLUDE ZIP CODE) 10A. ATTORNEY - NAME 11A. PLACE OF THIS MARRIAGE - CITY, TOWN OR VILLAGE 11B. COUNTY 11C. STATE (COUNTRY IF NOT USA) 11 APPROXIMATE DATE COUPLESEPARATED NUMBER OF CHILDREN EVER BORNALIVE OF THIS MARRIAGE (SPECIFY) 13B. NUMBER OF CHILDREN UNDER 18 IN THIS FAMILY (SPECIFY) 12A. DATE OF THISMARRIAGE Month Day Year 12B. Month Year 13A. 14A. Month Day Year14B. DATE Month Day Year 14C. I CERTIFY THAT A DECREE OFDISSOLUTION OF THE ABOVE MARRIAGE WAS RENDERED ON TYPE OF DECREE - DIVORCE, ANNULMENT, OTHERDISSOLUTION (SPECIFY) OF ENTRY: 15 14D. COUNTY OF DECREE 14E. TITLE OF COURT DECREE14F. SIGNATURE OF COUNTY CLERK 23 > CONFIDENTIAL INFORMATION 15. RACE: WHITE, BLACK, AMERICAN INDIAN, OTHER (SPECIFY) 16. NUMBER OF THIS MARRIAGE - FIRST, 17. IF PREVIOUSLY MARRIED HOW MANY ENDED BY 18. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY 24 SECOND, ETC. (SPECIFY) ELEMENTARY HIGH SCHOOL COLLEGE A. DEATH B. DIVORCE OR ANNULMENT012345678 1234 12345+ 01 02 03 04 05 06 07 08 10 11 12 14 15 16 17 NUMBER NUMBER 00 09 13 NONE NONE RACE: WHITE, BLACK, AMERICAN INDIAN, OTHER (SPECIFY) NUMBER OF THISMARRIAGE - FIRST, IF PREVIOUSLY MARRIEDHOW MANY ENDED BY 19. 20. 21. 22. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY SECOND, ETC. (SPECIFY) ELEMENTARY HIGH SCHOOL COLLEGE A. DEATH B. 25 DIVORCE ORANNULMENT012345678 1234 12345+ 01 02 03 04 05 06 07 08 10 11 12 14 15 16 17 00 09 13 NUMBER NUMBER NONE NONE 23. PLAINTIFF: 24. DECREE GRANTED TO: 25. LEGAL GROUNDS FOR DECREE (SPECIFY) QR 26. SIGNATURE OF PERSON PREPARING CERTIFICATE QS > ATTORNEY AT LAW NOTE: Social Security Numbers of the parties to the marriage are mandatory. They are required by New York State Public Health Law Section 4139 and 42 U.S.C. 666(a). They may be used for child support enforcement purposes. DOH-2168 (7/2011) Wife/Husband/Spouse 1A. NAME: FIRST MIDDLE LAST 1B. BIRTH NAME, IF DIFFERENT Wife/Husband/ Spouse Wife/Husband/Spouse 3. SEX (Optional) 7A. DATE OF BIRTH 9A. RESIDENCE: STATE 9B. COUNTY 9C. LOCALITY (CHECK ONE AND SPECIFY) Month CITY OF TOWN OF VILLAGE OF Day Year Month Day Year 7B. STATE OF BIRTH (COUNTRY IF NOT USA) 8. SEX (Optional)