Form Dh-Phs-Marlic-2012 - Vermont License And Certificate Of Civil Marriage Template
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2DH-PHS-MARLIC-2012
DEPARTMENT OF HEALTH
VERMONT LICENSE AND CERTIFICATE OF CIVIL MARRIAGE
LOCAL FILE NUMBER
STATE FILE NUMBER
APPLICANT A
BRIDE
GROOM
SPOUSE
(check one)
1a. LEGAL NAME (First, Middle, Last)
1b. LAST NAME AT BIRTH (Maiden Surname)
2. SEX
3. DATE OF BIRTH (Month, Day, Year)
4. BIRTHPLACE (State or Foreign Country)
TYPE OR
PRINT IN
BLACK INK
5a. RESIDENCE ADDRESS (Number and Street)
5b. CITY OR TOWN OF RESIDENCE
5c. STATE OF RESIDENCE
5d. COUNTRY OF RESIDENCE
6a. FATHER’S OR PARENT’S NAME (First, Middle, Last Name at Birth)
6b. BIRTHPLACE (State or Foreign Country)
7a. MOTHER’S OR PARENT’S NAME (First, Middle, Last Name at Birth)
7b. BIRTHPLACE (State or Foreign Country)
BRIDE
GROOM
SPOUSE
(check one)
APPLICANT B
8a. LEGAL NAME (First, Middle, Last)
8b. LAST NAME AT BIRTH (Maiden Surname)
9. SEX
10. DATE OF BIRTH (Month, Day, Year)
11. BIRTHPLACE (State or Foreign Country)
12a. RESIDENCE ADDRESS (Number and Street)
12b. CITY OR TOWN OF RESIDENCE
12c. STATE OF RESIDENCE
12d. COUNTRY OF RESIDENCE
13a. FATHER’S OR PARENT’S NAME (First, Middle, Last Name at Birth)
13b. BIRTHPLACE (State or Foreign Country)
14a. MOTHER’S OR PARENT’S NAME (First, Middle, Last Name at Birth)
14b. BIRTHPLACE (State or Foreign Country)
We/I hereby certify that the information provided is correct to the best of our/my knowledge and belief and that we are free to marry under the laws of Vermont.
15a. SIGNATURE (Applicant A)
15b. DATE SIGNED
16a. SIGNATURE (Applicant B)
16b. DATE SIGNED
CERTIFICATION
OFFICIANT
I hereby certify that the above named persons have made
(See instructions on back)
oath to the truth of the facts stated in the foregoing declaration of intention of
This license authorizes the marriage IN VERMONT ONLY of the above named parties by any person duly
marriage and complied with the marriage laws of the State of Vermont.
authorized to perform a marriage.
17a. DATE ON WHICH LICENSE WAS ISSUED (Month, Day, Year)
18b. WHERE MARRIED – CITY OR TOWN
18a. I CERTIFY THAT THE ABOVE PERSONS WERE
MARRIED ON (Month, Day, Year)
17b. TOWN CLERK (Signature)
18c. SIGNATURE OF PERSON PERFORMING CEREMONY
18d. TITLE
17c. TOWN OR CITY
18e. NAME (Type/Print)
18f. TELEPHONE NUMBER
18g. MAILING ADDRESS OF PERSON PERFORMING CEREMONY (Number and Street, City or Town, State, Zip Code)
17d. THIS LICENSE IS VALID FROM ________________________________________________ TO
DATE
_____________________________________________.
DATE
REGISTRATION
19a. CLERK’S SIGNATURE
19b. DATE RECEIVED BY LOCAL REGISTRAR
20a. TRUE COPY – (Clerk’s Signature)
20b. TOWN
20c. DATE
ATTEST:
CONFIDENTIAL INFORMATION
THE INFORMATION BELOW MUST BE COMPLETED. IT WILL NOT APPEAR ON CERTIFIED COPIES OF THE RECORD.
APPLICANT A
21. LEGAL NAME (First, Middle, Last)
21a. I FREELY AND VOLUNTARILY AGREE TO DISSOLVE OUR CIVIL UNION CERTIFIED
IN VERMONT.
SIGNATURE:
22. TOTAL NO. OF MARRIAGES
23a. LAST MARRIAGE OR CIVIL UNION ENDED BY (check one)
23b. DATE LAST MARRIAGE OR CIVIL UNION ENDED
AND CIVIL UNIONS, INCLUDING
THIS ONE
Death
Divorce
Dissolution
Annulment
Civil union did not end;
Month _______________________________ Year _________________
marrying civil union partner
APPLICANT B
24. LEGAL NAME (First, Middle, Last)
24a. I FREELY AND VOLUNTARILY AGREE TO DISSOLVE OUR CIVIL UNION CERTIFIED
IN VERMONT.
SIGNATURE:
25. TOTAL NO. OF MARRIAGES
26a. LAST MARRIAGE OR CIVIL UNION ENDED BY (check one)
26b. DATE LAST MARRIAGE OR CIVIL UNION ENDED
AND CIVIL UNIONS, INCLUDING
THIS ONE
Death
Divorce
Dissolution
Annulment
Civil union did not end;
Month _______________________________ Year _________________
marrying civil union partner
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