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Rst, Middle, Last) DEPARTMENT OF PUBLIC HEALTH & SOCIAL SERVICES OFFICE OF VITAL STATISTICS HUSBAND 2a. RESIDENCE CITY, TOWN, OR LOCATION 2c. STATE 3. BIRTHPLACE (State or Foreign Country) 5a. WIFE S NAME (First, Middle, Last) WIFE 4. DATE OF BIRTH (Month, Day, Year) 5b. MAIDEN NAME 6a. RESIDENCE CITY, TOWN, OR LOCATION 6b. COUNTY 6c. STATE MARRIAGE 7. BIRTHPLACE (State or Foreign Country) 9a. PLACE OF THIS MARRIAGE CITY, TOWN, OR LOCATION 9b. COUNTY 11. DATE COUPL.

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