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Marriage Certificate document sample
Document Sample
TYPE / PRINT 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, Year) 5. SOCIAL SECURITY NO.
6a. FATHER'S NAME (First, Middle. Last) 6b. BIRTHPLACE (State 7a. MOTHER'S NAME (First, Middle. Maiden) 7b. BIRTHPLACE (State or
or Foreign Country) Foreign Country)
8a. BRIDE'S NAME (First, Middle. Last) 8b. MAIDEN SURNAME (If different) 9. AGE LAST BIRTHDAY
DEPARTMENT OF HEALTH AND HUMAN SERVICES — PUBLIC HEALTH SERVICE — NATIONAL CENTER FOR HEALTH STATISTICS — 1989 REVISION
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. Maiden) 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 OF THIS STATE.
SIGNATURE 15. GROOM'S SIGNATURE 16. BRIDE'S SIGNATURE
This License Authorizes the Marriage in This State of the Parties Named Above By Any 17. EXPIRATION DATE (Month, Day, Year)
Person Duly Authorized to Perform a Marriage Ceremony Under the Laws of the
State of
LICENSE
TO MARRY 18. SUBSCRIBED TO AND SWORN TO BEFORE 19. SIGNATURE OF ISSUING OFFICIAL 20. TITLE OF ISSUING OFFICIAL
ME ON: (Month, Day, Year)
21. I CERTIFY THAT THE ABOVE NAMED 22a. WHERE MARRIED – CITY, TOWN, OR LOCATION
22b. ISLAND
PERSONS
WERE MARRIED ON: (Month, Day, Year)
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
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
Place of Birth
Nationality U.S. CITIZEN U.S. CITIZEN
Usual Residence CITY, STATE CITY, STATE
Previous Marital Status
Related to other Applicant? No No
In what degree? N/A N/A
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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