TYPE OR PRINT IN PERMAMENT INK

ORIGINAL

Name of County

STATE OF ILLINOIS

CERTIFICATE OF DISSOLUTION

INVALIDITY OF MARRIAGE OR LEGAL SEPARATION

State File Number

Court File Number

1.

Husband – Name

First

Middle

Last

HUSBAND

2a.

Residence – City, Town, Twp., or Road District Number

2b.  County

2c.  State

3. State of Birth (If Not  in U.S., Name Country)

4a.  Date of Birth (Mo., Day, Year)

4b.  Age Now

5a.

Wife – Name

First

Middle

Last

5b.  Maiden Name

WIFE

PRINTED BY AUTHORITY OF THE STATE OF ILLINOIS

6a.

Residence – City, Town, Twp., or Road District Number

6b.  County

6c.  State

7. State of Birth (If Not in U.S., Name Country)

8a.  Date of Birth (Mo., Day, Year)

8b.  Age Now

9a.

Date of This Marriage (Mo., Day, Year)

9b.  Place of This Marriage – City

9c.  County

9d.  State (If Not in U.S., Name Country)

10.

Date Couple Last Resided in Same Household (Month,   Day,   Year)

11a.  Number of Children Born Alive of This Marriage

11b.

Children Under 18 in This Household (Specify)

12.

Petitioner-Husband, Wife, Both, Other (Specify)

13a.

Type of Decree (Specify: Dissolution, Invalidity, or Legal Separation)

13b.

Legal Grounds for Decree

(Specify)

14.

Number of Children Under 18 Whose Physical Custody Was Awarded To:

15.

Legal Representative-Name and Address (Street or R.F.D., City or Town, State, Zip)

Husband ___________

Wife ______________

  No Children

Joint (Husband/Wife) ________  Other  _____________

FOR COURT CLERK ONLY

16.

Date of Recording Decree (Month,    Day,      Year)

17.

Signature of Court Clerk

►

INFORMATION FOR STATISTICAL PURPOSES ONLY

Race

Number of This Marriage

If Previously Married, Last Marriage Ended By

Education (Specify Highest Grade Completed)

HUSBAND

18.

Specify (e.g. White, Black, American Indian, etc.)

19.  First, Second, etc.

20a.  By Death, Dissolution, or Invalidity?  Specify:

20b.  Date (Month, Day, Year)

21a.  Elementary or Secondary

(0-12)

21b..  College (1-4 or  5+)

WIFE

22.

Specify (e.g. White, Black, American Indian, etc.)

23.  First, Second, etc.

24a.  By Death, Dissolution, or Invalidity? Specify:

24b.  Date (Month, Day, Year)

25a. Elementary or Secondary

(0-12)

25b..  College (1-4or  5+)

26.

Of Hispanic Origin?

27a.

  No   Yes

27b.

  No     Yes

(Specify No or Yes – If yes, specify Cuban,  Mexican, Puerto Rican, etc.)

HUSBAND

Specify:

WIFE

Specify:

VR700 (1989)

Illinois Department of Public Health – Office of Vital Records

BASED ON 1989 US STANDARD CERT.