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Certificate of Dissolution

DOH 422-027 March 2015 Certificate of Dissolution Declaration of Invalidity of Marriage or Legal Separation Please Type or Print in Permanent Black Ink 1. Court File Number State File Number 15. Spouse A Social Security Number Decree I certify the marriage of the persons named below was ordered as a 2. Legal Separation Dissolution of Marriage Declaration of Invalidity 3. Date of Decree MM / DD / YYYY 4. County of Decree 5.

DOH 422-027 March 2015 . Certificate of Dissolution . Declaration of Invalidity of Marriage . or Legal Separation . Please Type or Print in Permanent Black Ink

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