Marriage Application Form For Service
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2P.E.I. Vital Statistics, Dept. of Health
APPLICATION FOR SERVICE
P.O.Box 3000, Montague, PEI C0A 1R0
(Section 32 of the Act)
Telephone:(902)838-0880 Fax:(902)838-0883
Name of Applicant:
Method of payment: (must accompany application):
Money Order
Visa Mastercard
Mailing Address:
Card #______________________________
City/Province:
Postal/Zip code
Exp. Date ________Signature ___________________
Phone.: (H) __________ (W)____________ Relationship to person named on certificate:_________________________
Specific reason certificate is required:
If birth certificate required, complete this section (PLEASE PRINT)
Last name at Birth:_________________________1st Given Name: _____________________2nd Given Name:________________
Male
Other Given Names:__________________________________ Female
Date of birth:___________________/_____/_____
Month (written out)
day
year
Place of birth (city, town or village)______________________________, PRINCE EDWARD ISLAND
Surname of Mother(At Her Birth):____________________Given name(s):______________________Birthplace:______________
nd
Surname of 2
Parent (at Birth):____________________ Given name(s):______________________Birthplace:_______________
Standard
Detailed /
Regular Service
Rush Service
Type:
If marriage certificate required, complete this section (PLEASE PRINT)
Last name of spouse________________________ Given name(s):_________________________Birthplace:__________________
Last name of spouse________________________ Given name(s):_________________________Birthplace:__________________
Date of marriage:____________________ /_____ /_____ Place of marriage (city/town/village):______________________, PEI
Month (written out)
Day
Year
Detailed
Regular Service
Type:
/
If death certificate(s) required, complete this section (PLEASE PRINT)
Surname of deceased:_________________________________ Given name(s):________________________________________
Male
Female
Date of death:_________________/_____/_____
Age: ______ Date of birth:___________________/_____/_____
Month(written out)
Day
Year
Month(written out)
Day
Year
Place of death:_______________________ , PEI
Usual Residence prior to death:_____________________________________
Single
Married
Widow
Marital Status:
Divorced
Certificate of Death
Regular Service
Type:
/
X
________________________________________
_____________________________________________
Signature of applicant
Date of application
FOR OFFICE USE ONLY
Receipt No.___________
Invoice No.___________ Certificate typed by: ____________ Date Issued ___________
Registration Date:_________ Registration No._______________ Certificate No.____________ Fee Chg’d _______
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