The marriage between husband
is dissolved and this was registered in the civilian registry book, record # — from —-
Last name given after divorce:
to him: —
to her: —
Place of registration: registry office of Municipal Administrationof Justice —.
State authority that issued the certificate: registry office of Municipal Administrationof Justice of —-.
The certificate is given to citizen —
Data of issue: —
Signature of the head of the
registry office: signature —
Round official seal
Ministry of Justice of Ukraine
registry office of municipal Administration of Justice of —-