Form Dhhs 1607 - Work Sheet For Preparation Of Marriage License Form - N.c. Department Of Health And Human Services

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WORK SHEET FOR PREPARATION OF MARRIAGE LICENSE FORM
______________________________________
________________________________________
LICENSE NUMBER
COUNTY
1a. NAME
FIRST
MIDDLE
LAST
1b. LAST NAME AT BIRTH (If Different)
1c. GENDER (Optional)
2a. RESIDENCE–STATE
2b. COUNTY
2c. CITY, TOWN, OR LOCATION
2d. INSIDE CITY LIMITS
(Specify Yes or No)
APPLICANT
2e. STREET AND NUMBER
3. BIRTHPLACE (COUNTY & STATE)
4a. DATE OF BIRTH (Month, Day, Year)
4b. AGE
1
5a. PARENT’S NAME AT PARENT’S BIRTH
5b. STATE OF BIRTH
5c. ADDRESS (If Living)
6a. PARENT’S NAME AT PARENT’S BIRTH
6b. STATE OF BIRTH
6c. ADDRESS (If Living)
7. RACE (Optional)
8. NUMBER OF THIS
IF PREVIOUSLY MARRIED
10. EDUCATION–SPECIFY HIGHEST GRADE COMPLETED
MARRIAGE – FIRST,
9a. LAST MARRIAGE ENDED BY:
9b. DATE
ELEMENTARY
HIGH SCHOOL
COLLEGE
SECOND, ETC. (Specify)
Death, Divorce, Or Annulment (Specify)
MONTH
YEAR
(0,1,2,3,4, ... or 8)
(1, 2, 3, or 4)
(1, 2, 3, 4, or 5)
11a. NAME
FIRST
MIDDLE
LAST
11b. LAST NAME AT BIRTH (If Different)
11c. GENDER (Optional)
12a. RESIDENCE–STATE
12b. COUNTY
12c. CITY, TOWN, OR LOCATION
12d. INSIDE CITY LIMITS
(Specify Yes or No)
APPLICANT
2
12e. STREET AND NUMBER
13. BIRTHPLACE (COUNTY & STATE)
14a. DATE OF BIRTH (Month, Day, Year)
14b. AGE
15a. PARENT’S NAME AT PARENT’S BIRTH
15b. STATE OF BIRTH
15c. ADDRESS (If Living)
16a. PARENT’S NAME AT PARENT’S BIRTH
16b. STATE OF BIRTH
16c. ADDRESS (If Living)
17. RACE (Optional)
18. NUMBER OF THIS
IF PREVIOUSLY MARRIED
20. EDUCATION–SPECIFY HIGHEST GRADE COMPLETED
MARRIAGE – FIRST,
19a. LAST MARRIAGE ENDED BY:
19b. DATE
ELEMENTARY
HIGH SCHOOL
COLLEGE
SECOND, ETC. (Specify)
Death, Divorce, Or Annulment (Specify)
MONTH
YEAR
(0,1,2,3,4, ... or 8)
(1, 2, 3, or 4)
(1, 2, 3, 4, or 5)
DHHS 1607 (Revised 10/2014)
N.C. DEPARTMENT OF HEALTH AND HUMAN SERVICES
N.C. Vital Records
RACE (Optional)
ABBREVIATIONS
RACE (Optional)
ABBREVIATIONS
White . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wht
Native Hawaiian . . . . . . . . . . . . . . . . NatHaw
Black . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Blk
Guamarian . . . . . . . . . . . . . . . . . . . . . Guam
African-American . . . . . . . . . . . . . . . . . AfrAm
Chamorro . . . . . . . . . . . . . . . . . . . . . . Cham
American Indian. . . . . . . . . . . . . . . . . . AmInd
Samoan. . . . . . . . . . . . . . . . . . . . . . . . .Samo
Alaska Native. . . . . . . . . . . . . . . . . . . . AlaNat
Other Pacifi c Islander . . . . . . . . . . . . OPacIs
Asian Indian. . . . . . . . . . . . . . . . . . . . . AsInd
Mexican. . . . . . . . . . . . . . . . . . . . . . . . . Mexi
Chinese . . . . . . . . . . . . . . . . . . . . . . . . . Chin
Mexican-American . . . . . . . . . . . . . . MexAm
Filipino . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fili
Chicano . . . . . . . . . . . . . . . . . . . . . . . . . Chica
Japanese . . . . . . . . . . . . . . . . . . . . . . . . Japa
Puerto Rican . . . . . . . . . . . . . . . . . . . . PueRi
Korean . . . . . . . . . . . . . . . . . . . . . . . . . . Kore
Cuban . . . . . . . . . . . . . . . . . . . . . . . . . . Cuba
Vietnamese . . . . . . . . . . . . . . . . . . . . . . . Viet
Other Spanish/Hispanic/Latino . . . . OSpHiLa
Other Asian . . . . . . . . . . . . . . . . . . . . . . OAsi
Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Oth

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