Marriage Certificate - Excel

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					     TYPE IN                                                                                                                                                                                VIRGIN ISLANDS OF THE UNITED STATES
   PERMANENT
   BLACK INK.
                                                                                                                                                                                      LICENSE AND CERTIFICATE OF MARRIAGE
FOR INSTRUCTIONS                                                                                                                                            LICENSE NUMBER                                                                                                STATE FILE NUMBER
 SEE HANDBOOK.
                                                                                                                                       1. GROOM'S NAME (First, Middle. Last)                                                                                                    2. AGE LAST BIRTHDAY



                                                                                                                                       3a. RESIDENCE – CITY, TOWN, OR LOCATION                                                          3b. COUNTY OR ISLAND



                                                                                                                             GROOM     3c. STATE                                            4a. BIRTHPLACE (State or Foreign Country) 4b. DATE OF BIRTH (Month, Day,            5. SOCIAL SECURITY NO.



                                                                                                                                       6a. FATHER'S NAME (First, Middle. Last)                6b. BIRTHPLACE (State         7a. MOTHER'S NAME (First, Middle. Last)             7b. BIRTHPLACE (State or
                                                                                                                                                                                                  or Foreign Country)                                                               Foreign Country)
DEPARTMENT OF HEALTH AND HUMAN SERVICES — PUBLIC HEALTH SERVICE — NATIONAL CENTER FOR HEALTH STATISTICS — 1989 REVISION




                                                                                                                                       8a. BRIDE'S NAME (First, Middle. Last)                                         8b. MAIDEN SURNAME (If different)                         9. AGE LAST BIRTHDAY



                                                                                                                                       10a. RESIDENCE – CITY, TOWN, OR LOCATION                                                         10b. COUNTY OR ISLAND



                                                                                                                              BRIDE    10c. STATE                                                                                    11b. DATE OF BIRTH (Month, Day,
                                                                                                                                                                                            11a. BIRTHPLACE (State or Foreign Country)                                          12. SOCIAL SECURITY NO.



                                                                                                                                       13a. FATHER'S NAME (First, Middle. Last)               13b. BIRTHPLACE (State 14a. MOTHER'S NAME (First, Middle. Last)                   14b. BIRTHPLACE (State or
                                                                                                                                                                                                     or Foreign Country)                                                              Foreign Country)




                                                                                                                                              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.
                                                                                                                          SIGNATURES   15. GROOM'S SIGNATURE                                                                16. BRIDE'S SIGNATURE



                                                                                                                                                                                                                         17.
                                                                                                                                       This License Authorizes the Marriage in This State of the Parties Named Above By Any EXPIRATION DATE (Month, Day, Year)
                                                                                                                                       Person Duly Authorized to Perform a Marriage Ceremony Under the Laws of the
                                                                                                                                       State of
                                                                                                                             LICENSE
                                                                                                                                       18. SUBSCRIBED TO AND SWORN TO BEFORE                19. SIGNATURE OF ISSUING OFFICIAL                          20. TITLE OF ISSUING OFFICIAL
                                                                                                                            TO MARRY       ME ON: (Month, Day, Year)



                                                                                                                                       21. I CERTIFY THAT THE ABOVE NAMED                   22a. WHERE MARRIED – CITY, TOWN, OR LOCATION
                                                                                                                                                                                                                                       22b. ISLAND
                                                                                                                                       PERSONS



                                                                                                                                       23a. SIGNATURE OF PERSON PERFORMING CEREMONY                                   23b. NAME (Type/Print)               23c. TITLE


                                                                                                                           CEREMONY
                                                                                                                                       23d. ADDRESS OF PERSON PERFORMING CEREMONY (Street and Number or Rural Route Number, City or Town, State, Zip Code)



                                                                                                                                       24a. SIGNATURE OF WITNESS TO CEREMONY                                                24b. SIGNATURE OF WITNESS TO CEREMONY



                                                                                                                                       25. SIGNATURE OF COURT REGISTRATION OFFICIAL                                                         26. DATE FILED BY COURT (Month, Day, Year)
                                                                                                                             LOCAL
                                                                                                                            OFFICIAL


                                                                                                                                              CONFIDENTIAL INFORMATION. THE INFORMATION BELOW WILL NOT APPEAR ON CERTIFIED COPIES OF THE RECORD.
                                                                                                                                                                    28. IF PREVIOUSLY MARRIED, LAST MARRIAGE                                                                30. EDUCATION
                                                                                                                                        27. NUMBER OF THIS
                                                                                                                                                                                         ENDED                                  29. RACE – American               (Specify only highest grade completed)
                                                                                                                                            MARRIAGE –
                                                                                                                                                                      By Death, Divorce,                                      Indian, Black, White, etc.
                                                                                                                                            First, Second, etc.                                                                                             Elementary/Secondary                College
                                                                                                                                                                   Dissolution, or Annulment Date (Month, Day, Year)               (Specify below)
                                                                                                                                               (Specify below)                                                                                                     (0-12)                     (1-4 or 5+)
                                                                                                                                                                          (Specify below)
                                                                                                                                       27a.                        28a.                       28b.                          29a.                           30a.
                                                                                                                             GROOM

                                                                                                                                       27b.                        28c.                       28d.                          29b.                           30b.
                                                                                                                              BRIDE




                                                                                                                          PHS-T-004
                                                                                                                          REV. 1/89
(Please Type)                                                                                                No.
                                 APPLICATION FOR MARRIAGE LICENSE

We                                                            of                                ,
                                                                                       (Permanent Residence)

and                                                           of                                ,
                                                                                       (Permanent Residence)

      do hereby apply for and request that a marriage licence be granted us to enter into marriage in
                   St. Thomas                    ,Virgin Islands, and we do further respectfully represent that
      the following statements are true and correct:


                          MALE                                                            FEMALE
Full Name

SS No.

Date of Birth             January 1, 1904                                           January 1, 1904
Place of Birth

Nationality

Usual Residence                          ,                                                      ,
Previous Marital Status

Related to other Applicant?

In what degree?


Parents:

      Present Name

      Maiden Name

      Place of Birth                         /                                                      /
Signature

      PLEASE CHECK THIS BOX IF YOU ARE                             THE COURT, HAVING REVIEWED THIS APPLICATION
      REQUESTING EXEMPTION TO THE EIGHT-DAY                        FOR MARRIAGE LICENSE, DETERMINING THAT
      POSTING REQUIREMENT EXPLAINED IN THE                         SPECIAL CIRCUMSTANCES EXIST TO ISSUE A
      ATTACHED MARRIAGE INFORMATION FACT                           LICENSE WITHOUT THE POSTING REQUIRED BY
      SHEET.                                                       TITLE 16 SECTION 38 OF THE VIRGIN ISLANDS
      WE ARE REQUESTING EXEMPTION BECAUSE
      OF THE FOLLOWING SPECIAL

                                                                                              JUDGE




Subscribed and sworn to by each of the parties this       day of                                               ,
License issued this             day of                                      ,
Filed this             day of                                      ,


                                                                   Clerk of the Territorial Court
                                                                   By:
                                                                                              Deputy Clerk

				
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