Statistical Record Of Divorce Page 2
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1
2Certifier
16. I certify that the marriage of the above named
17. Type of Decree
18. County in which Decree
persons was dissolved on: (Month/date/year)
Issued
Divorce
Dissolution
Annulment
19. Number of children under 18 whose physical
20. Recorded in:
custody was awarded to:
Book
Husband/Partner
Page
Wife/Partner
(SEAL)
Joint
Other
No Children
21. Signature of Chancery Clerk or Deputy
Date signed
(Month/day/year)
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