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Fill and Sign the Vital Statistics Form State of Wyoming Department of Health Absolute Divorce or Annulment for Plaintiff Without Children Wyoming

Fill and Sign the Vital Statistics Form State of Wyoming Department of Health Absolute Divorce or Annulment for Plaintiff Without Children Wyoming

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VITAL STATISTICS FORM State of Wyoming Department of Health ABSOLUTE DIVORCE OR ANNULMENT STATE FILE NUMBER ______________________ 1. HUSBAND’S NAME (First, Middle, Last) 2a. RESIDENCE-CITY, TOWN, OR LOCATION 2b. COUNTY 2c. STATE Birthplace (State or Foreign Country) 4. DATE OF BIRTH (Month, Day, Year) 5a. WIFE’S NAME (First, Middle, Last) 5b. MAIDEN SURNAME 6a. RESIDENCE-CITY, TOWN, OR LOCATION 6b. COUNTY 6c. STATE 7. BIRTHPLACE (State or Foreign Country) 8. DATE OF BIRTH (Month, Day, Year) 9a. PLACE OF THIS MARRIAGE-CITY TOWN, OR LOCATION 9b. COUNTY 9c. STATE OR FOREIGN COUNTRY 10. DATE OF THIS MARRIAGE (Month, Day, Year) 11. DATE COUPLE LAST RESIDED IN SAME HOUSEHOLD (Month, Day, Year) 12. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS OF THE DATE IN ITEM 11 Number _____ None 13. PLAINTIFF/PETITIONER Husband Wife Both Other (Specify) 14a. NAME OF PLAINTIFF/PETITIONER’S ATTORNEY ----------------DO NOT FILL OUT BELOW THIS LINE 14b. ADDRESS (Street and Number or Rural Route Number, City or Town, State, Zip Code) 15. I CERTIFY THAT THE MARRIAGE OF THE ABOVE NAMED PERSONS WAS DISSOLVED ON : (Month, Day, Year) 16. TYPE OF DECREE-Divorce or Annulment (Specify) 17. DATE RECORDED (Month, Day, Year) _ 18. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED TO: Husband Wife Joint (Husband/Wife) Other No Children 19. COUNTY OF DECREE 20. TITLE OF COURT 21. SIGNATURE OF CERTIFYING OFFICIAL 22. TITLE OF CERTIFYING OFFICIAL 23. DATE SIGNED (Month, Day, Year) Vital Statistics Form Revised February 2011 Page 1 of 1

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