Fill and Sign the Vital Statistics Form Delaware

Form 441 (Rev 04/12) CERTIFICATE OF DIVORCE OR ANNULMENT State of Delaware DIVISION OF PUBLIC HEALTH OFFICE OF VITAL STATISTICS STATE FILE COPY HEALTH STATISTICS COPY FAMILY COURT COPY State File No.       A T T Y Petitioner (check one) Name of Petitioner’s Attorney Attorneys Address (number, street, town, State & Zip) Husband Wife Both             Other ( specify)       H U S B A N D 1. Husband’s Name (First – Middle – Last) 2. SSN             3a. Residence (Number and Street) 3b. City 3c. County                   3d. State 3e. Zip Code 4. Birthplace (State or Foreign Country) 5. Date of Birth (mm/dd/yyyy)                         6. Race (Check which race you consider yourself to be.) White Black or African American American Indian or Alaska Native 6b. Hispanic Origin (Check box with Selection) No, not Spanish/Hispanic/Latina Yes, Mexican, Mexican American, Chicana Yes, Puerto Rican Yes, Cuban Yes, Other Spanish/Hispanic/Latina 8. Number of this marriage 1 st , 2 nd , etc. (specify below)       (Name of principal tribe)       9. If previously married: Date of your last previous marriage (Month, Day, Year)       Asian Indian Chinese Filipino Japanese Korean Vietnamese (specify)       9b. Preceding marriage ended by (check one) Death Divorce Annulment7. Education (check one) 8 th grade or less 9 th -12 th grade, but no diploma High school graduate or GED completed Some college credit, but no degree Associate degree Bachelor’s degree Master’s degree Doctorate or professional degree Other Asian (specify)       Native Hawaiian Guamanian or Chamorro 9c. Date preceding marriage ended (Month, Day, Year)       Samoan Other Pacific Islander (specify)       Other (specify)       W I F E 10. Wife’s Name (First – Middle – Last) 11. Wife’s Last Name Prior to First Marriage 12. SSN                   13a. Residence (Number and Street) 13b. City 13c. County                   13d. State 13e. Zip Code 14. Birthplace (State or Foreign Country) 15. Date of Birth (mm/dd/yyyy)                         16. Race (Check which race you consider yourself to be.) White Black or African American American Indian or Alaska Native 16b. Hispanic Origin (Check box with Selection) No, not Spanish/Hispanic/Latina Yes, Mexican, Mexican American, Chicana Yes, Puerto Rican Yes, Cuban Yes, Other Spanish/Hispanic/Latina 18. Number of this marriage 1 st , 2 nd , etc. (specify below)       (Name of principal tribe)       19. If previously married: Date of your last previous marriage (Month, Day, Year)       Asian Indian Chinese Filipino Japanese Korean Vietnamese (specify)       19b. Preceding marriage ended by (check one) Death Divorce Annulment17. Education (check one) 8 th grade or less 9 th -12 th grade, but no diploma High school graduate or GED completed Some college credit, but no degree Associate degree Bachelor’s degree Master’s degree Doctorate or professional degree Other Asian (specify)       19c. Date preceding marriage ended (Month, Day, Year)       Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander (specify)       Other (specify)       M A R R I A G E 20. Date of this marriage (Month, Day, Year) 21a. Place where this marriage took place (city, 21b. County 21c. State or Foreign Country       Town or Location)                   22. Date couple last resided in same household 23. Number of children under 18 in this household as of date in item 22 23b. Number of children whose physical custody was awarded to:             Husband    Wife    Joint (Husband/Wife)    Other       No Children CONTESTED? No Yes ********** FOR OFFICIAL USE ONLY ********** D E C R E E 24. I certify that the marriage of the named persons was dissolved on (MM/DD/YYYY) 25. Type of Decree (check one) 26. County of Decree (check one) 27. Date Recorded (MM/DD/YYYY)       Divorce Annulment New Castle Kent Sussex       28. Title of Court 29. Signature of Certifying Official 30. Title of Certifying Official 31. Date Signed ( MM/DD/YYYY)       CLERK OF COURT       ATTORNEY – Complete items 1-23b when filing petition and leave with Clerk of the Court CLERK OF COURT – After final decree, complete items 24-31 and forward to: Office of Vital Statistics, 417 Federal Street, Dover, DE 19901