| DEPARTMENT OF HEALTH AND HUMAN SERVICES — PUBLIC HEALTH SERVICE
— NATIONAL CENTER FOR HEALTH STATISTICS — 1989 REVISION |
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VIRGIN ISLANDS OF
THE UNITED STATES
LICENSE AND CERTIFICATE OF MARRIAGE |
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LICENSE NUMBER |
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STATE FILE NUMBER |
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1. GROOM'S NAME (First,
Middle. Last) |
2. AGE LAST BIRTHDAY |
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3a. RESIDENCE – CITY, TOWN, OR LOCATION |
3b. COUNTY OR ISLAND |
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3c. STATE |
4a. BIRTHPLACE (State or Foreign Country) |
4b. DATE
OF BIRTH (Month, Day, Year) |
5. SOCIAL SECURITY NO. |
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6a. FATHER'S NAME (First,
Middle. Last) |
6b. BIRTHPLACE (State
or Foreign Country) |
7a. MOTHER'S NAME (First,
Middle. Last) |
7b.
BIRTHPLACE (State or
Foreign Country) |
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8a. BRIDE'S NAME (First,
Middle. Last) |
8b. MAIDEN SURNAME (If different) |
9. AGE LAST BIRTHDAY |
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10a. RESIDENCE – CITY, TOWN, OR LOCATION |
10b. COUNTY OR ISLAND |
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10c. STATE |
11a. BIRTHPLACE (State or Foreign Country) |
11b.
DATE OF BIRTH (Month, Day, Year) |
12. SOCIAL SECURITY NO. |
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165-60-6519 |
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13a. FATHER'S NAME (First,
Middle. Last) |
13b. BIRTHPLACE (State
or Foreign Country) |
14a. MOTHER'S NAME (First,
Middle. Last) |
14b.
BIRTHPLACE (State or
Foreign Country) |
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WE HERBY CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE
BEST OF OUR KNOWLEDGE AND BELIEF
AND THAT WE ARE FREE TO MARRY UNDER THE LAWS OD THIS STATE. |
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15. GROOM'S
SIGNATURE |
16. BRIDE'S SIGNATURE |
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This License
Authorizes the Marriage in This State of the Parties Named Above By Any |
17. EXPIRATION DATE (Month, Day, Year) |
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Person Duly
Authorized to Perform a Marriage Ceremony Under the Laws of the |
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State of |
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18. SUBSCRIBED TO AND
SWORN TO BEFORE
ME ON: (Month,
Day, Year) |
19. SIGNATURE OF ISSUING
OFFICIAL |
20. TITLE OF ISSUING OFFICIAL |
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21. I CERTIFY THAT THE
ABOVE NAMED PERSONS
WERE MARRIED ON: (Month, Day, Year) |
22a. WHERE MARRIED – CITY, TOWN, OR LOCATION |
22b. ISLAND |
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23a. SIGNATURE OF PERSON PERFORMING CEREMONY |
23b. NAME (Type/Print) |
23c. TITLE |
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23d. ADDRESS OF PERSON PERFORMING CEREMONY (Street and Number or Rural Route Number, City or Town, State,
Zip Code) |
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24a.
SIGNATURE OF WITNESS TO CEREMONY |
24b. SIGNATURE OF WITNESS TO CEREMONY |
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25. SIGNATURE OF COURT REGISTRATION OFFICIAL |
26. DATE FILED BY COURT (Month, Day, Year) |
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CONFIDENTIAL INFORMATION. THE INFORMATION BELOW WILL NOT APPEAR ON
CERTIFIED COPIES OF THE RECORD. |
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27. NUMBER OF THIS MARRIAGE –
First, Second, etc.
(Specify below) |
28. IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED |
29. RACE – American Indian, Black, White,
etc.
(Specify below) |
30. EDUCATION
(Specify only highest grade completed) |
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By Death, Divorce, Dissolution, or Annulment (Specify
below) |
Date (Month, Day, Year) |
Elementary/Secondary
(0-12) |
College
(1-4 or 5+) |
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27a. |
28a. |
28b. |
29a. |
30a. |
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27b. |
28c. |
28d. |
29b. |
30b. |
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PHS-T-004
REV. 1/89 |
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