Certificate Of Dissolution Of Marriage
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1MISSOURI DEPARTMENT OF HEALTH
TYPE/PRINT
IN
CERTIFICATE OF DISSOLUTION OF MARRIAGE
PERMANENT
BLACK INK.
FOR
CASE NUMBER
STATE FILE NUMBER
INSTRUCTIONS
SEE HANDBOOK.
1. HUSBAND'S NAME (First, Middle, Last)
1a. SOCIAL SECURITY NO.
2a. RESIDENCE - CITY, TOWN, OR LOCATION
2b. STATE
2c. ZIP CODE
HUSBAND
2d. COUNTY
3. DATE OF BIRTH (Month, Day, Year)
4. BIRTHPLACE (State or Foreign Country)
VS 800
Rev. 6/97
MO 580-0716
5a. WIFE's NAME (First, Middle, Last)
5b. MAIDEN SURNAME
5c. SOCIAL SECURITY NO.
(6/97)
6a. RESIDENCE - CITY, TOWN, OR LOCATION
6b. STATE
6c. ZIP CODE
WIFE
6d. COUNTY
7. DATE OF BIRTH (Month, Day, Year)
8. BIRTHPLACE (State or Foreign Country)
9a. PLACE OF THIS MARRIAGE - CITY, TOWN OR LOCATION
9b. COUNTY
9c. STATE OR FOREIGN COUNTRY
10. DATE OF THIS MARRIAGE
(Month, Day, Year)
MARRIAGE
11. DATE COUPLE LAST RESIDED IN SAME
12. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS OF
13. PETITIONER
HOUSEHOLD (Month, Day, Year)
THE DATE IN ITEM 11
W i f e 2
Joint
0
H u s b a n d 1
Number
None
3
Other (Specify)
14a. NAME OF PETITIONER'S ATTORNEY (Type or Print)
14b. ADDRESS (Street and Number or Rural Route Number, City or Town, State, Zip code)
ATTORNEY
16. TYPE OF DECREE
17. DATE RECORDED (Month, Day, Year)
15. I CERTIFY THAT THE MARRIAGE OF THE ABOVE-NAMED
PERSONS WAS DISSOLVED ON:
(Month, Day, Year)
0
Dissolution 1
L e g al Se p a ra t io n
2
A n n u l me n t
18. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS
19. CHILD SUPPORT WAS AWARDED
21. TITLE OF COURT
20. COUNTY OF DECREE
AWARDED TO:
TO:
1
H u s b a n d
DECREE
H u s b a n d
W ife
2
W ife
Joint (Husband/Wife)
O t h e r
O t h e r
4
No children
No child support awarded
3
22. SIGNATURE OF CERTIFYING OFFICIAL
23. TITLE OF CERTIFYING OFFICIAL
24. NUMBER OF THIS
27. EDUCATION
25. IF PREVIOUSLY MARRIED, LAST MARRIAGE ENDED
MARRIAGE -
(Specify only highest grade completed)
26. RACE - American Indian, Black, White, etc.
First, Second, etc.
By:
Date: (Month, Year)
(Specify below)
Elementary/Secondary
College
(Specify below)
(1 - 4 or 5+)
(0 -12)
27a.
26a. 1
White
25a.
25c.
24a.
2
Death
2
Black
HUSBAND
3
Divorce, dissolution,
3
American Indian
or annulment
4
Other (Specify)
27b.
25d.
24b.
25b.
26b. 1
White
2
Death
2
Black
WIFE
3
Divorce, dissolution,
3
American Indian
or annulment
4
Other (Specify)
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