VITAL STATISTICS FORM State of Wyoming Department of Health ABSOLUTE DIVORCE OR ANNULMENT
1. HUSBAND'S NAME (First, Middle, Last)
STATE FILE NUMBER ______________________
2a. RESIDENCE-CITY, TOWN, OR LOCATION
2b. COUNTY
2c. STATE
Birthplace (State or Foreign Country)
4. DATE OF BIRTH (Month, Day, Year)
5a. WIFE'S NAME (First, Middle, Last)
5b. MAIDEN SURNAME
6a. RESIDENCE-CITY, TOWN, OR LOCATION
6b. COUNTY
6c. STATE
7. BIRTHPLACE (State or Foreign Country)
8. DATE OF BIRTH (Month, Day, Year)
9a. PLACE OF THIS MARRIAGE-CITY TOWN, OR LOCATION
9b. COUNTY
9c. STATE OR FOREIGN COUNTRY
10. DATE OF THIS MARRIAGE (Month, Day, Year)
11. DATE COUPLE LAST RESIDED IN SAME HOUSEHOLD (Month, Day, Year)
12. NUMBER OF CHILDREN UNDER 18 IN THIS HOUSEHOLD AS OF THE DATE IN ITEM 11 Number _____ None
13. PLAINTIFF/PETITIONER Husband Wife Both Other (Specify)
14a. NAME OF PLAINTIFF/PETITIONER'S ATTORNEY
14b. ADDRESS (Street and Number or Rural Route Number, City or Town, State, Zip Code)
----------------DO NOT FILL OUT BELOW THIS LINE
15. I CERTIFY THAT THE MARRIAGE OF THE ABOVE NAMED PERSONS WAS DISSOLVED ON : (Month, Day, Year) 16. TYPE OF DECREE-Divorce or Annulment (Specify) 17. DATE RECORDED (Month, Day, Year) _
18. NUMBER OF CHILDREN UNDER 18 WHOSE PHYSICAL CUSTODY WAS AWARDED TO: Wife Husband Joint (Husband/Wife) Other No Children 21. SIGNATURE OF CERTIFYING OFFICIAL
19. COUNTY OF DECREE
20. TITLE OF COURT
22. TITLE OF CERTIFYING OFFICIAL
23. DATE SIGNED (Month, Day, Year)
DNCP 4 Vital Statistics Form July 2006 Page 1 of 1