State of Nebraska – Department of Health and Human Services Finance and Support – VITAL RECORDS MARRIAGE WORKSHEET

1.  GROOM – Name (First, Middle, Last, Suffix)

2.   Age

3a.   COUNTRY

3b. STATE

3c. COUNTY

3d.   CITY, TOWN OR LOCATION

3e. RESIDENCE – Street and Number

3f.  ZIP CODE

4.   BIRTHPLACE (City and State or Foreign Country)

5.  DATE OF BIRTH (Mo., Day, Yr.)

6a.  FATHER’S – Name (First, Middle, Last, Suffix)

6b.  BIRTHPLACE (City and State or Foreign Country)

7a.  MOTHER’S – Full Maiden Name (First, Middle, Last, Suffix)

7b.  BIRTHPLACE (City and State or Foreign Country)

8a.  BRIDE – Name (First, Middle, Last, Suffix)

8b. MAIDEN NAME (If different)

9. AGE

10a.   COUNTRY

10b.  STATE

10c.  COUNTY

10d.  CITY, TOWN OR LOCATION

10e. RESIDENCE – Street and Number

10f.  ZIP CODE

11.  BIRTHPLACE (City and State or Foreign Country)

12.  DATE OF BIRTH (Mo., Day, Yr.)

13a.  FATHER’S – Name (First, Middle, Last, Suffix)

13b. BIRTHPLACE (City and State or Foreign Country)

14a. MOTHER’S – Full Maiden Name (First, Middle, Last, Suffix)

14b. BIRTHPLACE (City and State or Foreign Country)

CONFIDENTIAL INFORMATION: INFORMATION BELOW WILL NOT APPEAR ON CERTIFIED COPIES OF THIS RECORD.

15.  SOCIAL SECURITY NUMBER – Groom

15b.  SOCIAL SECURITY NUMBER – Bride

16.  If previously married, last marriage ended either by –

Groom:

Death

Dissolution

Annulment

Date Marriage Ended (Mo., Day, Yr.)

Bride:

Death

Dissolution

Annulment

Date Marriage Ended (Mo., Day, Yr.)

17a.   Is Husband of Hispanic or Latino Origin?

Yes

No

17b. Is Bride of Hispanic or Latino Origin?

Yes

No

Race

18a. Husband

18b. Wife

Check one or more races to indicate what each person considers him/herself to be

White/Caucasian

Black or African American

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

HS-68 6/06 (55068)