Department Of Health Certificate Of Divorce Dissolution Of Marriage Or Annulment

- ------------------------ 0 TYPE IN PERMANENT INK COURT IDENTIFICATION (Court File Number) GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF HEALTH CERTIFICATE OF DIVORCE, DISSOLUTION OF MARRIAGE OR ANNULMENT 108 FILE NUMBER HUSBAND-NAME FIRST MIDDLE LAST > c. o o ~ o o ::J c 1. USUAL RESIDENCE STREET ADDRESS CITY, TOWN OR LOCATION ii: z ~ en ::;) J: « In z 2a. COUNTY 2b. STATE DATE OF BIRTH (Mo, Day, Yr) 2c. 3. 4. WIFE-NAME FIRST MIDDLE LAST MAIDEN NAME o o > c. u, 5a. 5b. STREET ADDRESS CITY, TOWN OR LOCATION w USUAL RESIDENCE - ...I c:( i= o en 3= 6a. COUNTY 6b. STATE DATE OF BIRTH (Mo, Day, Yr) ~ j;i ~ ...I ...I 6c. 7. 8. > W DATE OF THIS MARRIAGE (Mo. Day, Yr.) CHILDREN UNDER 18 IN THIS FAMILY (Specify) PLANTIFF CHECK HUSBAND WIFE BOTH OTHER (Specify) 10. 9. ATTORNEY FOR PLANTIFF-NAME (Type or Print) 12. W 11. ADDRESS OF ATTORNEY-STREET OR R.F.D. NO. CITY OR TOWN STATE ZIP 13. ...I u::: I Z W Z TYPE OF DECREE CHECK DIVORCE DISSOLUTION ANNULMENT c:( :!: a: w c. en Q a: o o w a: o w c a: w w THIS DECREE IS GRANTED ON (MONTH DAY YEAR.) ONLY COURT RECORDS CAN INDICATE THE DATE ON WHICH A DECREE BECOMES FINAL. --- ------ 15. TITLE OF COURT SUPERIOR COURT OF THE DISTRICT OF COLUMBIA 14. SIGNATURE OF CERTIFYING OFFICIAL 16. TITLE OF OFFICIAL CLERK OF THE COURT 17. 18. ...I ~ l- ;: i: ~ c INFORMATION FOR STATISTICAL PURPOSES ONLY RACE-HUSBAND Specify (e.g., White, Black, American Indian, etc.) 19. DHS-1601 (7/97) NUMBER OF THIS MARRIAGE Specify (First, second, etc.) RACE-WIFE Specify (e.g., White, Black, American Indian, etc.) 21. NUMBER OF THIS MARRIAGE Specify (First, second, etc.) ::;) en J: « In z WIFE 20. 22. 97-0960 PM5 THIS CERTIFICATE IS TO BE FILED WITH THE CLERK OF THE COURT WITH THE PETITION American LegalNet, Inc. www.FormsWorkFlow.com