Marriage in Extremis |
I, the undersigned ........................... Status Officer of (1) ........................ and we, the undersigned ..................... of (2) and of (2) ........................... being of the age of 18 years and upwards do hereby certify that on the ........................... day of ..........................., ........................, the ceremony of marriage was performed by me the said ........................ in the presence of us the said ................................. and ................................. between .................. of ..................... (3) .............................. and ................................. of ..................... (4) ................................. and that both the said .............................. and .............................. at the time of the performance of such ceremony were legally competent to contract marriage, and were of full age, and that the said (5) ..................... was a member of the same religious communion or denomination to which the said (6) ........................ belongs, that is to say, the (7) ........................; and that at the time of the performance of such ceremony, the said (8) ........................... was, to the best of our knowledge and belief, in a dying state. |
Signatures. |
(1) Residence. |
(2) Residence and Profession. |
(3) State whether bachelor or widower. |
(4) State whether spinster or widow. |
(5) Name of party in dying state. |
(6) Name of Status Officer. |
(7) Religious communion or denomination. |
(8) Name of party in dying state. |