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E/COUNTRY 10B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY) 11A. FULL BIRTH NAME OF MOTHER/PARENT 11B. STATE OF BIRTH (IF OUTSIDE U.S. ENTER COUNTRY) Groom Bride SECOND PERSON DATA 12D. LAST NAME AT BIRTH (IF DIFFERENT THAN 12C) 13. DATE OF BIRTH (MM/DD/CCYY) 14. STATE/COUNTRY OF BIRTH 15. # PREV. MARRIAGES/SRDP 16A. LAST MARRIAGE/SRDP ENDED BY: 16B. DATE ENDED (MM/DD/CCYY) DEATH DISSO ANNULMENT TERM SRDP N/A 17. ADDRESS 18. CITY 21A. FULL BIRTH NAME OF FATHER/.

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