Name (as recorded on marriage license): Date of Birth:
Marriage Certificate No.:
Date of Marriage or Period
Covered by Search:
Purpose for which record is required:
In what capacity are you acting?:
What is your relationship to person whose record is required?
(If self, state "SELF".)
If attorney, give name and relationship of your client to person whose record is required:
Bride/Groom/Spouse
If Previously Married, State Name Used at that Time: Residence (at time of marriage):
Place Where Marriage License Was Issued:
Bride/Groom/Spouse
If Previously Married, State Name Used at that Time:
Name (as recorded on marriage license): Date of Birth:
Residence (at time of marriage):
Marriage Information
Place Where Marriage Was Performed: Local Registration No.:
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