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Fill and Sign the State of Utah Department of Health Certificate of Divorce Dissolution of Form

Fill and Sign the State of Utah Department of Health Certificate of Divorce Dissolution of Form

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STATE OF UTAH - DEPARTMENT OF HEALTH CERTIFICATE OF DIVORCE, DISSOLUTION OF MARRIAGE, OR ANNULMENT 2a. RESIDENCE - CITY, TOWN OR LOCATION 2b. COUNTY 2c. STATE 3. BIRTHPLACE (State or Foreign Country) 4. BIRTHDATE (MM/DD/YY) 5. NUMBER OF THIS MARRIAGE - First, Second, etc. (Specify) 7. RACE: White, Black, American Indian, etc. (Specify) 8. EDUCATION: (Specify only highest grade completed) Elementary/Secondary (0 - 12) College (13-16 or 17+) 10b. COUNTY 10a. RESIDENCE - CITY, TOWN OR LOCATION 15 . RACE: White, Black, American Indian, etc. (Specify) Date (MM/DD/YY) By Death, Divorce, Dissolution, or annulment (Specify) 14. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED: 13. NUMBER OF THIS MARRIAGE - First, Second, etc. (Specify) 12. BIRTHDATE (MM/DD/YY) 11. BIRTHPLACE (State or Foreign Country) 10c. STATE College (13-16 or 17+) Elementary/Secondary (0 - 12) 16. EDUCATION: (Specify only highest grade completed) 6. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED: Date (MM/DD/YY) By Death, Divorce, Dissolution, or annulment (Specify) 17a. PLACE OF THIS MARRIAGE - CITY TOWN, OR LOCATION 17b. COUNTY 17c. STATE OR FOREIGN COUNTRY 18. DATE OF THIS MARRIAGE (MM/DD/YY) 19. DATE COUPLE LAST RESIDED IN SAME HOUSEHOLD (MM/DD/YY) 20. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS OF THE DATE IN ITEM 19 Number_________ None 21. PETITIONER Spouse 1 Both Spouse 2 Other, Specify ____________ 22a. NAME OF PETITIONER'S ATTORNEY (Type/Print) 22b. ADDRESS (Street and Number or Rural Route Number, City, or Town, State, Zip Code) SPOUSE 1 SPOUSE 2 MARRIAGE ATTORNEY DECREE 23. I CERTIFY THAT THE MARRIAGE OF THE ABOVE NAMED PERSONS WAS DISSOLVED ON (MM/DD/YY) 24. TYPE OF DECREE, Divorce, Dissolution, or Annulment (Specify) 25. DATE RECORDED (MM/DD/YY) 28. TITLE OF COURT 27. COUNTY OF DECREE 26. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED TO: Spouse 1_______ Spouse 2_______ Joint__________ Other _________ Not Determined Yet No Children 25. DATE SIGNED (MM/DD/YY) 30. TITLE OF CERTIFYING OFFICIAL 29. SIGNATURE OF CERTIFYING OFFICIAL UDOH OVRS Form 404 Rev. 01/16 1d. Last Name 1c. Last name before first marriage, if applicable 1b. Middle Name 1a. First Name 9d. Last Name 9c. Last name before first marriage, if applicable 9b. Middle Name 9a. First Name 1e. Sex F M 9e. Sex F M

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