Utah Certificate of Divorce Form
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STATE OF UTAH - DEPARTMENT OF HEALTH
CERTIFICATE OF DIVORCE, DISSOLUTION
OF MARRIAGE, OR ANNULMENT
1. HUSBAND'S NAME (First, Middle, Last)
2a. RESIDENCE - CITY, TOWN OR LOCATION
2c. STATE

HUSBAND

2b. COUNTY

3. BIRTHPLACE (State or Foreign Country)

5. NUMBER OF THIS 6. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED:
MARRIAGE First, Second, etc. By Death, Divorce, Dissolution, Date (Mo., Day, Yr.)
(Specify below)
or Annulment (Specify Below)

7. RACE: White, Black, 8. EDUCATION: (Specify only
highest grade completed)
Amer. Indian, etc.
Elementary/Secondary
College
(Specify below)

9a. WIFE'S NAME (First, Middle, Last)

9b. MAIDEN LAST NAME

(0 - 12)

10a. RESIDENCE - CITY, TOWN OR LOCATION
10c. STATE

WIFE

11. BIRTHPLACE (State or Foreign Country)

MARRIAGE

17a. PLACE OF THIS MARRIAGE - CITY,
TOWN, OR LOCATION

(13-16 or 17+)

10b. COUNTY

13. NUMBER OF THIS 14. IF NOT FIRST MARRIAGE, LAST MARRIAGE ENDED:
MARRIAGE First, Second, etc. By Death, Divorce, Dissolution, Date (Mo., Day, Yr.)