License And Certificate Of Marriage

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VS-3 Rev. 10/08
STATE OF CONNECTICUT
Type or print clearly
DEPARTMENT OF PUBLIC HEALTH
with permanent black ink.
Vital Records Section – Hartford, Connecticut 06134
STATE FILE NO
Complete every item
.
LICENSE AND CERTIFICATE OF MARRIAGE: Town of ___________________________________________________
BRIDE/ GROOM/ SPOUSE
BRIDE/ GROOM/ SPOUSE
NAME
(First)
(Middle)
(Last)
NAME
(First)
(Middle)
(Last)
.
1
22.
SEX
DATE OF BIRTH
AGE
SEX
DATE OF BIRTH
AGE
(Mo., Day, Year)
(Mo., Day, Year)
24.
2.
3.
4.
23.
25.
BIRTHPLACE (State or Foreign Country)
EDUCATION (No. Yrs. Completed)
BIRTHPLACE (State or Foreign Country
EDUCATION (No. Yrs. Completed)
)
GRADES 1-8
GRADES 9-12
COLLEGE (1-5+)
GRADES 1-8
GRADES 9-12
COLLEGE (1-5+)
26.
5.
6.
7.
8.
27.
28.
29.
RESIDENCE (No. and Street)
RESIDENCE (No. and Street)
9.
30.
CITY OR TOWN
COUNTY
STATE
CITY OR TOWN
COUNTY
STATE
10.
11.
12.
31.
32.
33.
RACE
SUPERVISION OR CONTROL BY GUARDIAN OR
RACE
SUPERVISION OR CONTROL BY GUARDIAN OR
YES
NO
YES
NO
14. CONSERVATOR
35. CONSERVATOR
13.
34.
FATHER’S NAME
FATHER’S NAME
15.
36.
FATHER’S BIRTHPLACE
MOTHER’S BIRTHPLACE
(
FATHER’S BIRTHPLACE
MOTHER’S BIRTHPLACE
(State or Foreign Country)
State or Foreign Country)
(State or Foreign Country)
(State or Foreign Country)
16.
17.
37.
38.
MOTHER’S MAIDEN NAME
MOTHER’S MAIDEN NAME
18.
39.
NO. OF THIS
NO. OF CIVIL
21a. IF PREVIOUSLY IN MARRIAGE OR CIVIL UNION, LAST
NO. OF THIS
NO. OF CIVIL
42a. IF PREVIOUSLY IN MARRIAGE OR CIVIL UNION, LAST
MARRIAGE
UNIONS
MARRIAGE
UNIONS
RELATIONSHIP WAS 1.
MARRIAGE 2.
CIVIL UNION
RELATIONSHIP WAS 1.
MARRIAGE 2.
CIVIL UNION
19.
20.
40.
41.
21b. LAST RELATIONSHIP ENDED BY: 1.
DEATH 2.
DISSOLUTION 3.
ANNULMENT
42b. LAST RELATIONSHIP ENDED BY: 1.
DEATH 2.
DISSOLUTION 3.
ANNULMENT
4.
PREVIOUS CIVIL UNION DID NOT END. MARRYING CIVIL UNION PARTNER
4.
PREVIOUS CIVIL UNION DID NOT END. MARRYING CIVIL UNION PARTNER
We, the above named in this marriage license do solemnly swear that the statements herein made are true.
SIGNATURE OF BRIDE/ GROOM/ SPOUSE
SWORN TO ME (Registrar’s Signature)
THIS DAY OF (Month, Day, Year)
43.
44.
45.
LICENSE
SIGNATURE OF BRIDE/ GROOM/ SPOUSE
SWORN TO ME (Registrar’s Signature)
THIS DAY OF (Month, Day, Year)
46.
47.
48.
This license certifies that the above-named persons have complied with the laws of Connecticut relating to a marriage license, and any person
THIS LICENSE MUST BE
DATE (Month, Day, Year)
Registrar of
authorized to celebrate a marriage may join the above-named in marriage in the town of:
USED ON OR BEFORE
Vital Records
49.
50.
ISSUING OFFICIAL (Signature)
TITLE
DATE ISSUED (Month, Day, Year)
51.
52.
53.
I HEREBY CERTIFY THAT
AND
OFFICIATOR
54.
55.
THE ABOVE NAMED PARTIES WERE LEGALLY JOINED IN MARRIAGE BY
IN THE COUNTY OF
THIS DAY (Month, Day, Year)
ME IN THE TOWN OF
56.
57.
58.
SIGNATURE OF PERSON PERFORMING
PERSON PERFORMING CEREMONY (Please Print)
OFFICIAL CAPACITY
TYPE OF CEREMONY
CEREMONY
59.
60.
61.
62.
THIS CERTIFICATE RECEIVED FOR RECORD ON Date: (Month, Day, Year)
BY (Signature)
REGISTRAR
63.
64.
SOCIAL SECURITY # OF BRIDE/ GROOM/ SPOUSE
SOCIAL SECURITY # OF BRIDE/ GROOM/ SPOUSE
ADMINISTRATIVE
65.
66.

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