DIVORCE CERTIFICATE. Civil Status Registry Office of Sovetsky district of the city of Nizhny Novgorod

DIVORCE CERTIFICATE

The marriage between

Citizen________________________________

(last name, first name, patronymic name)

And

Citizen _________________________________

(last name, first name, patronymic name)

Was dissolved with registration thereof in the Divorce Register on 01-01-2016 under No. __

Upon marriage dissolution the following surnames were assigned

To him __________

To her _______________.

Place of registration__________________________

This Certificate has been issued to citizen_________________

(last name, first name, patronymic name)

Place of state registration (location of CSRO):

Civil Status Registry Office of Sovetsky district of the city of Nizhny Novgorod

Name of the Department/Division of the Civil Status Registry Office

Date of issue ***

Head of the Department/Division of the Civil Status Registry Office /Signature/ ***

I-TH No. ***

/Seal: the Main Directorate of Civil Status Registry Offices for Nizhny Novgorod Region, Civil Status Registry Office of Sovetsky district of the city Nizhny Novgorod/

Goznak Moscow Printing Factory. 1998