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<br /> STATE OF HAWAII OFFICE OF HEALTH STATUS MONITORING <br /> DEPARTMENT OF HEALTH 1 ~ S' ZOO» <br /> APPLICATION FOR COMMISSION TO PERFORM MARRIAGE <br /> PLEASE PRINT: \ l CYt~ `5~1~ O NQ l ( I <br /> 1. Full name of applicant (No initials) N\a t `(M,ew.~ _ <br /> 2 (7F,nt~) I <br /> 2. Residence ~ ~X ~J- ~~'t `~OC~ ~ <br /> Qom-, , c~ ~m ~~~.1 °I 6`l ~ ~ <br /> q (SUae1 AtlMws a Bax No., M. Sba aneyZgCoasl <br /> 3. Mailing address ~3 ~o a~b <br /> ~a~Gl~ Z ~ ( lJ~ ~ 5. Place of birth f ~'4~,I ~ ' <br /> 4. Date of birth o~y (crryarrow s~.mac«,m~rl <br /> Z~-- YQ <br /> 6. Citizen of USA? x Yes _ No 7. Length of residence in Hawaii _ <br /> 8. Can you read and write English? ~ Yes - No 8a. Telephone: Res. ~ ~ ~ 3~~ Bus. ~ <br /> 3~s <br /> 9. Have you ever been licensed in the past to perform marriages in the State of Hawaii? _ Yes ~ No <br /> If yes, when? <br /> 10. Have you performed any marriages in the State of Hawaii prior to this application? _ Yes ~ No <br /> If yes, please give date and place of marriage: <br /> NOTE: Questions 11-15 to be answered by ministers and others w~ hto perform religious marria a cerelnonv <br /> v ~ ~~IstiS a-~ I~((~~``~_~~~~ <br /> 11. Place ordained or appointed (Church, organization, etc.): O <br /> City & State or Country ' <br /> C' avt nab. ~ q <br /> 12. Date ordained or appointed ~ U ~ ~ ~ Z~ ~ 13. Deno~nat' or sect ..r.~ <br /> r1~.} Ali <br /> 14. Present church or ot{{h~~e-~r organizational affiliation ~ ~ ~ J ~ <br /> Address WX, ~-2)~-~ ~~~"'_1'__(t~~~' 15. Yourtkle <br /> NOTE: Questions 16-18 to be answered by persons who perform civil marriage ceremony. <br /> 16. Present office held, e.g., judge <br /> 17. Name of organization, e.g., district court <br /> 18. Date of appointment <br /> 11 1 <br /> I CERTIFY THAT THE ABOVE INFORMATION Si nature of Applicant I`w~ <br /> IS TRUE AND CORRECT. g <br /> NOTE: Application must be accompanied by a letter recommending the granting of a license from one of the folbwing: <br /> 1. For ministers, a letter from the head of his denomination in Hawaii. <br /> 2. For persons pertorming civil ceremony, a letter from the appointing authority. <br /> BELOW FOR OFFICE USE ONLY <br /> Sighted: Completed: <br /> Date received ( )Log <br /> Approved by Date ( )Driver's License # ( )Index Card <br /> ( )State I.D. # ( )Index Card for <br /> License No. District Health Office <br /> Date issued ( )Ordination Card # ( )Computer <br /> ( )Other: ( )License Mailed <br /> Completed by Date <br /> <br />