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Vermont Department of Health Record of Divorce or Annulment Form

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Vermont Department of Health Record of Divorce or Annulment Form
Vermont Department of Health Record of Divorce or Annulment Form
MARRIAGE
DECREE
9/09 SML
DEPARTMENT OF HEALTH
VERMONT RECORD OF DIVORCE OR ANNULMENT
Docket #
1a. Name (First, Middle, Last)
2a. State of Residence
2b. City or Town of Residence
4a. Name (First, Middle, Last)
5a. State of Residence
5b. City or Town of Residence
7a. State or foreign country of this marriage
7b. City or Town of this marriage
7c. Date of this marriage
(month, day, year)
8b. Number of children under 18 in this household as of the date in item 8a.
10. I certify that this decree became absolute (final) on
11. Type of decree (check one)
12. County of decree
Name of Petitioner's Attorney
NO ATTORNEY
9a.
Divorce
Annulment
3. Date of Birth (month, day, year)
6. Date of Birth (month, day, year)
8a. Date couple last resided in same household
(month, day, year)
9b. Attorney's Address (street, city/town, state, zip)
/ /
/ /
/ /
/ /
Dept. of Health Use ONLY
State File # __________________________
/ /
14. Court Manager's Name
15. Date signed (month, day, year)
/ /
13. Legal grounds for decree (specify)
1c. Sex
Male
Female
4c. Sex
Male
Female
VDH-VR-DIV-9/2009
1b. Last Name at Birth
4b. Last Name at Birth
HUSBAND
WIFE SPOUSE (Check one)
APPLICANT A
HUSBAND
WIFE SPOUSE (Check one)
APPLICANT B
(month, day, year)
Vermont Department of Health Record of Divorce or Annulment Form