West Virginia Vital Statistics Form
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INFORMATION REQUESTED BY DIVISION OF VITAL STATISTICS

[Pertaining to Divorces and Annulments]
Chapter 16, Article 5, Section 34 of
Code of West Virginia, as Amended
_______________________________________________

Civil Action No. _______________________________________________________________
Husband's Full Name: __________________________________________________________
Wife's Maiden Name: ___________________________________________________________
Age of Husband: ___________________

Age of Wife: __________________

Place of Marriage: _____________________________________________________________
[COUNTY]

[STATE]

Date of Marriage: ______________________________________________________________
Name of Petitioner: ______________________________________________________________
Divorce:

9

Yes

9

No

Annulment:

Names of Children Under 18 Years of Age

9

Yes

9

No

Date of Birth

____________________________________________________________________________
_________________________