Number of  Copies: ___________________                                           FEE: [SEE FEE SCHEDULE FOR OPTIONS]

Name of Groom:_______________________________________________

Name of Bride: ________________________________________________

Date of Marriage: ________________________ Race: _________________

The Certificate of the above named person is for ( Circle one of the Following ):
 

1. My Own	6. I am seeking information for legal
2. My Child	determination of personal or property rights.
3. My Brother, Sister	7. I am an authorized agent, attorney or legal
4. My Spouse	representative of the person listed above. (Proof Required)
5. My Parent	8. Certificate Needed for __________________

I HEREBY CERTIFY THAT ALL OF THE ABOVE INFORMATION GIVEN IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF (NC GENERAL STATUTES 130A-93 AND 139A-99).

DATE: ______________	__________________________________________
	APPLICANT?S SIGNATURE

 ______________________________________________________________________________________
                                                             APPLICANT'S MAILING ADDRESS

FOR OFFICE USE ONLY

_________________________________________________________________________________

BOOK_____________________ PAGE___________________

GROOM?S NAME ___________________________________ AGE__________________

RESIDENCE__________________________________________________

BRIDE?S NAME ____________________________________ AGE____________________

RESIDENCE ________________________________________

DATE OF MARRIAGE ________________________________ FILE NUMBER__________

WITNESS __________________________________

WITNESS _______________________________ OFFICIATING_____________________

WITNESS _____________________________TITLE ___________________________

Register of Deeds, Marriage Division, P.O. Box 1107 27702, Tel. # (919)560-0493, Fax # (919) 560-0497