VS-3 Rev. 10/21
Type or print clearly
with permanent black ink.
Complete every item.
STATE OF CONNECTICUT
DEPARTMENT OF PUBLIC HEALTH
Vital Records Section – Hartford, Connecticut 06134
LICENSE AND CERTIFICATE OF MARRIAGE: Town of ___________________________________________________
SPOUSE ONE SPOUSE TWO
NAME (First) (Middle) (Last)
1.
NAME (First) (Middle) (Last)
21.
DATE OF BIRTH (Mo., Day, Year)
3.
AGE (If Minor, Probate Judge
permission Is Required)
4.
DATE OF BIRTH (Mo., Day, Year)
23.
AGE (If Minor, Probate Judge
permission Is Required)
24.
BIRTHPLACE (State or Foreign Country)
5.
EDUCATION (No. Yrs. Completed)
BIRTHPLACE (State or Foreign Country)
25.
EDUCATION (No. Yrs. Completed)
RESIDENCE (No. and Street)
9.
RESIDENCE (No. and Street)
29.
SUPERVISION OR CONTROL BY GUARDIAN OR CONSERVATOR
13. YES NO
SUPERVISION OR CONTROL BY GUARDIAN OR CONSERVATOR
33. YES NO
FATHER/PARENT NAME (LAST NAME PRIOR TO FIRST MARRIAGE)
14.
FATHER/PARENT NAME (LAST NAME PRIOR TO FIRST MARRIAGE)
34.
MOTHER/PARENT NAME (LAST NAME PRIOR TO FIRST MARRIAGE)
15.
MOTHER/PARENT NAME (LAST NAME PRIOR TO FIRST MARRIAGE)
35.
FATHER/PARENT BIRTHPLACE
(State or Foreign Country)
16.
MOTHER/PARENT BIRTHPLACE
(State or Foreign Country)
17.
FATHER/PARENT BIRTHPLACE
(State or Foreign Country)
36.
MOTHER/PARENT BIRTHPLACE
(State or Foreign Country)
37.
20a. IF PREVIOUSLY IN MARRIAGE OR CIVIL UNION, LAST
RELATIONSHIP WAS 1. MARRIAGE 2. CIVIL UNION
40a. IF PREVIOUSLY IN MARRIAGE OR CIVIL UNION, LAST
RELATIONSHIP WAS 1. MARRIAGE 2. CIVIL UNION
20b. LAST RELATIONSHIP ENDED BY: 1. DEATH 2. DISSOLUTION 3. ANNULMENT
4. PREVIOUS CIVIL UNION DID NOT END. MARRYING CIVIL UNION PARTNER
40b. LAST RELATIONSHIP ENDED BY: 1. DEATH 2. DISSOLUTION 3. ANNULMENT
4. PREVIOUS CIVIL UNION DID NOT END. MARRYING CIVIL UNION PARTNER
We, the above named in this marriage license sincerely affirm and declare that the statements herein made are true.
SIGNATURE OF SPOUSE ONE
41.
SIGNATURE OF REGISTRAR
42.
THIS DAY OF (Month, Day, Year)
43.
SIGNATURE OF SPOUSE TWO
44.
SIGNATURE OF REGISTRAR
45.
THIS DAY OF (Month, Day, Year)
46.
Registrar of
Vital Records
This license certifies that the above-named persons have complied with the laws of Connecticut relating to a marriage license, and any person
authorized to celebrate a marriage may join the above-named in marriage in the town of:
47.
THIS LICENSE MUST BE DATE (Month, Day, Year)
USED ON OR BEFORE
48.
ISSUING OFFICIAL (Signature)
49.
DATE ISSUED (Month, Day, Year)
51.
I HEREBY CERTIFY THAT
52.
THE ABOVE NAMED PARTIES WERE LEGALLY JOINED IN MARRIAGE BY
ME IN THE TOWN OF
54.
THIS DAY (Month, Day, Year)
56.
SIGNATURE OF PERSON PERFORMING CEREMONY
57.
PERSON PERFORMING CEREMONY (Please Print)
58.
THIS CERTIFICATE RECEIVED FOR RECORD ON DATE: (Month, Day, Year)
61.
SOCIAL SECURITY NUMBER - SPOUSE ONE
63.
SOCIAL SECURITY NUMBER - SPOUSE TWO
64.
