Free State of Wyoming - Wyoming

VITAL STATISTICS FORM State of Wyoming Department of Health ABSOLUTE DIVORCE OR ANNULMENT
1. HUSBAND'S NAME (First, Middle, Last)

STATE FILE NUMBER ______________________

2a. RESIDENCE-CITY, TOWN, OR LOCATION

2b. COUNTY

2c. STATE

Birthplace (State or Foreign Country)

4. DATE OF BIRTH (Month, Day, Year)

5a. WIFE'S NAME (First, Middle, Last)

5b. MAIDEN SURNAME

6a. RESIDENCE-CITY, TOWN, OR LOCATION

6b. COUNTY

6c. STATE

7. BIRTHPLACE (State or Foreign Country)

8. DATE OF BIRTH (Month, Day, Year)

9a. PLACE OF THIS MARRIAGE-CITY TOWN, OR LOCATION

9b. COUNTY

9c. STATE OR FOREIGN COUNTRY

10. DATE OF THIS MARRIAGE (Month, Day, Year)

11. DATE COUPLE LAST RESIDED IN SAME HOUSEHOLD (Month, Day, Year)

12. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS OF THE DATE IN ITEM 11 Number _____ None

13. PLAINTIFF/PETITIONER Husband Wife Both Other (Specify)

14a. NAME OF PLAINTIFF/PETITIONER'S ATTORNEY

14b. ADDRESS (Street and Number or Rural Route Number, City or Town, State, Zip Code)

----------------DO NOT FILL OUT BELOW THIS LINE
15. I CERTIFY THAT THE MARRIAGE OF THE ABOVE NAMED PERSONS WAS DISSOLVED ON : (Month, Day, Year) 16. TYPE OF DECREE-Divorce or Annulment (Specify) 17. DATE RECORDED (Month, Day, Year) _

18. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED TO: Wife Husband Joint (Husband/Wife) Other No Children 21. SIGNATURE OF CERTIFYING OFFICIAL

19. COUNTY OF DECREE

20. TITLE OF COURT

22. TITLE OF CERTIFYING OFFICIAL

23. DATE SIGNED (Month, Day, Year)

DWCP 4. Vital Statistics Form Revised July 2006 Page 1 of 1