Santa Clara — VS-122

Source: https://www.cdph.ca.gov/CDPH%20Document%20Library/ControlledForms/VS122.pdf

ORDER ESTABLISHING FACT OF MARRIAGE

In the Superior Court of the State of California

In and for the County of ____________________

In the matter of the petition of

---

Number __________________________________

To establish the fact of marriage of Department _ _______________________________ ______________________________________________ and

---

The verified petition of ______________________________________________________________ to establish the fact of

marriage of ___________________________________________________________________________________________ having

been filed herein on the ___________ day of _______________, A.D., 20, and such petition having by an order of

court been duly set for hearing on the ___________ day of ______________, A.D., 20, at the hour of __________

o’clock ____ m. of said day; and now on said day said matter coming on regularly for hearing and it appearing to the satisfaction of this

court from the evidence introduced that the said ____________________________________________________________________,

petitioner herein, is beneficially interested in establishing of record the fact of the marriage of said _____________________________

---

in that ______________________________________________________________________________________________________

---

___________________________________________________________________________________________________________,

and it appearing that on the ___________ day of _________________, A.D., 20, the marriage, each to each other,

of _____________________________________________________ and _______________________________________________

occurred, and was solemnized at _________________________________________, in the County of _________________________,

State or Country of __________________________________________; that said marriage has not been registered in conformity with

the provisions of law in effect at the time of said marriage, or such record has been lost or destroyed after having been filed; and no one

appearing at said hearing to oppose the making of this order;

It is therefore ordered, adjudged, and decreed that on the ______________ day of ____________________________, A.D.,

20________, the marriage, each to each other, of ____________________________________________________________ occurred

at _____________________________________________________________, County of ______________________________, State

or Country of ________________________________.

Done in court this ___________ day of ______________, A.D., 20.

►_________________________________________________________ Judge of the Superior Court

Before filing the above order, insert in the certificate form below, as of the date of the marriage, the personal and statistical particulars required for the records of the State Registrar. A certified copy of the above order must be filed with the State Registrar before the order shall become effective. USE BLACK INK ONLY.

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDS FORM VS 122 (Rev. 04/20)

COURT ORDER DELAYED CERTIFICATE OF MARRIAGE STATE OF CALIFORNIA

NO ERASURES, WHITEOUTS, PHOTOCOPIES, OR ALTERATIONS

---

STATE FILE NUMBER LOCAL REGISTRATION NUMBER

TYPE OR PRINT CLEARLY IN BLACK INK ONLY – THIS FORM BECOMES THE OFFICIAL MARRIAGE RECORD

1A. FIRST NAME 1B. MIDDLE

1C. CURRENT LAST 1D. LAST NAME AT BIRTH (IF DIFFERENT THAN 1C)

2. DATE OF BIRTH (MM/DD/CCYY) 3. STATE/COUNTRY OF BIRTH 4. # PREV. MARRIAGES/SRDP 5A. LAST MARRIAGE/SRDP ENDED BY: 5B. DATE ENDED
ide AT DEATH DISSO ANNULMENT TERM SRDP N/A (MM/DD/CCYY)
Br AD

N 6. ADDRESS 7. CITY 8. STATE / COUNTRY 9. ZIP CODE □ RSO PE oomr G RSTI 10A. MAILING ADDRESS (IF DIFFERENT) 10B. CITY 10C. STATE 10D. ZIP CODE □ F

11A. FULL BIRTH NAME OF FATHER/PARENT 11B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

12A. FULL BIRTH NAME OF MOTHER/PARENT 12B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

13A. FIRST NAME 13B. MIDDLE

13C. CURRENT LAST 13D. LAST NAME AT BIRTH (IF DIFFERENT THAN 13C)

A 14. DATE OF BIRTH (MM/DD/CCYY) 15. STATE/COUNTRY OF BIRTH 16. # PREV. MARRIAGES/SRDP 17A. LAST MARRIAGE/SRDP ENDED BY: 17B. DATE ENDED ideDAT DEATH DISSO ANNULMENT TERM SRDP N/A (MM/DD/CCYY) Br N 18. ADDRESS 19. CITY 20. STATE / COUNTRY 21. ZIP CODE □ RSO roomPED GN 22A. MAILING ADDRESS (IF DIFFERENT) 22B. CITY 22C. STATE 22D. ZIP CODE

□ SECO

23A. FULL BIRTH NAME OF FATHER/PARENT 23B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

24A. FULL BIRTH NAME OF MOTHER/PARENT 24B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)

FACTS OF 25. DATE OF MARRIAGE—MM/DD/CCYY 26. CITY/TOWN OF MARRIAGE 27. COUNTY OF MARRIAGE MARRIAGE

NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 1A – 1D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE (IF DIFFERENT THAN 1B AND 1C)

S 28A. FIRST - MUST BE SAME AS 1A 28B. MIDDLE 28C. LAST NAME )ANY NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 13A – 13D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE (IF DIFFERENT THAN 13B AND 13C) W F(I NE 29A. FIRST - MUST BE SAME AS 13A 29B. MIDDLE 29C. LAST

OFFERED FOR FILING PURSUANT TO ORDER NUMBER _______________________________________________________________________________

OF THE SUPERIOR COURT OF THE STATE OF CALIFORNIA, IN AND FOR THE COUNTY OF __________________________________________________

MADE THE _____________ DAY OF ____________________, A.D., 20, ESTABLISHING OF RECORD THE FACT OF MARRIAGE IN

STATE REGISTRAR THE STATE OR COUNTRY OF ______________________________. NO MARRIAGE CERTIFICATE HAS BEEN FOUND ON FILE IN THE OFFICE OF VITAL USE ONLY RECORDS FOR THE ABOVE PARTIES.

30. OFFICE OF VITAL RECORDS 31. DATE ACCEPTED FOR REGISTRATION

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDS FORM VS 122 (Rev. 04/20)