105.157 REV. 6/02 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS COUNTY STATE FILE NUMBER RECORD OF DIVORCE OR ANNULMENT STATE FILE DATE (CHECK ONE) HUSBAND 1. Name (First) (Middle) (Last) 2. Date of Birth (Month) (Day) (Year) 3. RESIDENCE Street or R.D. City, Boro. Or Twp. County State 4. PLACE OF BIRTH (State or Foreign Country) 5. NUMBER OF THIS MARRIAGE 6. RACE 7. USUAL OCCUPATION WHITE BLACK OTHER (Specify) WIFE 8. MAIDEN Name (First) (Middle) (Last) 9. Date of Birth (Month) (Day) (Year) 10. RESIDENCE Street or R.D. City, Boro. Or Twp. County State 11. PLACE OF BIRTH (State or Foreign Country) 12. NUMBER OF THIS MARRIAGE 13. RACE 14. USUAL OCCUPATION WHITE BLACK OTHER (Specify) 15. PLACE OF THIS MARRIAGE (County) (State or Foreign County) 16. DATE OF THIS MARRIAGE (Month) (Day) (Year) 17A. NUMBER OF 17B. NUMBER OF 18. PLAINTIFF 19. DECREE GRANTED TO CHILDREN THIS DEPENDENT CHILDREN HUSBAND WIFE OTHER (Specify) HUSBAND WIFE OTHER (Specify) MARRIAGE UNDER 18 20. NUMBER OF CHILDREN TO CUSTODY OF 21. LEGAL GROUNDS FOR DIVORCE OR ANNULMENT HUSBAND WIFE SPLIT CUSTODY OTHER (Specify) 22. DATE OF DECREE (Month) (Day) (Year) 23. DATE REPORT SENT TO VITAL RECORDS (Month) (Day) (Year) 24. SIGNATURE OF TRANSCRIBING CLERK