Ministry of Justice of Ukraine
Main Department
In — oblast
Civilian Registry Office
—
Date 16—
# —
CERTIFICATE
Issued to —
This is to certify that on — under # — there was a marriage registered between — and —- in the Executive Committee of the town council of —, — Region, – oblast.
On —- the mentioned marriage was dissolved that was registered in the Department of civilian registry office in town of —- oblast under # —-.
Last name given after divorce:
to him: —-
to her: —
Round official seal
Signature of the acting as Head of the Department of civilian registry office: signature —-