Form Doh/chs 005 - Certificate Of Marriage - Washington State Department Of Health
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2Washington State
CERTIFICATE OF MARRIAGE
COUNTY OF LICENSE:
DATE VALID
NOT VALID AFTER
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Marriage ceremony must be performed in the State of Washington.
Please type or print clearly in permanent black ink.
State File Number
COUNTY AUDITOR
COUNTY AUDITOR’S SIGNATURE
DATE RECEIVED (MM|DD|YYYY)
X
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PERSON A
PERSON B
BRIDE GROOM SPOUSE
BRIDE GROOM SPOUSE
CHECK ONE
CHECK ONE
LEGAL NAME BEFORE MARRIAGE (FIRST/MIDDLE/LAST)
LEGAL NAME BEFORE MARRIAGE (FIRST/MIDDLE/LAST)
BIRTH NAME (IF DIFFERENT)
BIRTH NAME (IF DIFFERENT)
MALE
FEMALE
MALE
FEMALE
CURRENT RESIDENCE – STREET, CITY/TOWN
CURRENT RESIDENCE – STREET, CITY/TOWN
COUNTY OF RESIDENCE
STATE OF RESIDENCE
COUNTY OF RESIDENCE
STATE OF RESIDENCE
DATE OF BIRTH (MM|DD|YYYY)
BIRTH STATE (IF NOT USA, PROVIDE
DATE OF BIRTH (MM|DD|YYYY)
BIRTH STATE (IF NOT USA, PROVIDE
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COUNTRY)
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COUNTRY)
MOTHER/PARENT BIRTH NAME
MOTHER/PARENT BIRTH NAME
FATHER/PARENT BIRTH NAME
FATHER/PARENT BIRTH NAME
MOTHER/PARENT BIRTH STATE (OR
FATHER/PARENT BIRTH STATE (OR
MOTHER/PARENT BIRTH STATE (OR
FATHER/PARENT BIRTH STATE (OR
COUNTRY)
COUNTRY)
COUNTRY)
COUNTRY)
OFFICIANT
I certify that the undersigned, by authority of license issued by the County noted above, did on this day join in lawful wedlock with
their mutual consent in the presence of witnesses. In testimony whereof, witness our signatures:
DATE OF MARRIAGE (MM|DD|YYYY)
COUNTY OF CEREMONY
TYPE OF CEREMONY (CHECK ONE)
DATE SIGNED (MM|DD|YYYY)
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RELIGIOUS
CIVIL
OFFICIANT’S ADDRESS (STREET, CITY, STATE AND ZIP CODE) PLEASE PRINT
OFFICIANT’S DAYTIME PHONE
OFFICIANT’S NAME (PRINT)
OFFICIANT’S SIGNATURE
X
WITNESS SIGNATURE
WITNESS SIGNATURE
X
X
PERSON A SIGNATURE
DATE SIGNED (MM|DD|YYYY)
X
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PERSON B SIGNATURE
DATE SIGNED (MM|DD|YYYY)
X
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DOH/CHS 005 (REV 12/2012)
FORM VALID ON DECEMBER 6, 2012
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