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West Virginia Vital Statistics Form

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West Virginia Vital Statistics Form
West Virginia Vital Statistics Form
SCA-F-104 (Revised 12/01) VITAL STATISTICS
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:
9
Yes
9
No
Names of Children Under 18 Years of Age Date of Birth
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
______________________________________________________________________________
Date of Decree: ________________________________________________________________
[To be Completed by Clerk]
West Virginia Vital Statistics Form