Miscellaneous: DIONNE MARIE TUBERVILLE vs DAVID EDWARD TUBERVILLE

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                                INFORMATION ON SUIT AFFECTING THE FAMILY RELATIONSHIP
                                                             (EXCLUDING ADOPTIONS)
         SECTION I GENERAL INFORMATION (REQUIRED)                       STATE FILE NUMBER

         la.COUNTY  7arral1:zl:                       1b.COURTN0,..:.<~c.=.>,;'------1--~

         1c. CAUSE N J R D - Q i T o {       ~ /q                                                   R
                                                      1d. DATE OF ORDER (mm/dd/yyyy) .,_I.,_I1-%....JH-""

         2. TYPEOFORDER(CHECKALL THAT APPLY):

        ODIVORCE/ANNULMENTWIII:! CHILDREN (Sec. 1,2 AND 3)              •  DIVORCE/ANNULMENT WITHOUT CHILDREN (Sec 1 AND 2)

       ~TABLISHMENT OF COURT OF CONTINUING JURISDICTION (SEC 1 AND 3)
      ~ ; , , Order Establishing Paternity. Conservatorship, Child Support or Termination of Parental Rights)

        •  CHANGE IN THE NAME OF THE CHILD (SEC 1 AND 3)
         (PROVIDE PRIOR AND NEW NAME OF CHILD IN SECTION 3)

        •  TRANSFER OF COURT OR CONTINUING JURISDICTION (SEC1 ,3 AND INFORMATION BELOW)

         TRANSFER TO: COUNTY _ _ _ _ COURT NO. _ _ _ STATE COURTID#

                                                                                                                  area code)




                                                                                                   5. MAIDEN LAST NAME (IWAE BEFORE IS' MARRIAGE)

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           ~    6. PLACE OF BIRTH {CrTY AND STATE OR FOREIGN COUNTRY}          7. RACE                         {111lnlddl}'y)Y)
                                                                                                   8. DATE OF BIRTH

           ~
           W
              l-  c--~-~-----
                9. USUAL RESIDENCE
                                             -==~-~---=c
                                            STREET NAME& NUMBER
                                                                             1 - - ,STATE
                                                                          CITY
                                                                                      -,-~-L--           --,,~-----------l
                                                                                                        ZIP
           o..
                10. NAME (F1RSTMIDDLELASTSUFF1x}                                                   11. MAIDEN LAST NAME (NAME BEFORE fi>r MARRIAGE)
           ffi
           C    12 PL.ACE OF Bl All-I (CITY AND STATE OR FOREIGN COUNTRY)      13. RACE            14. DATE OF BIRTH (mmfdd.o/.YY.Y)


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           a:
                15. USUAL RESIDENCE (STREET NVD NUMBER CITY, STATE. ZIP)


                                                      (mmlclG»')'Y)
                                     17, DATE Of MARRIAGE            18. PLACE OF MARRIAGE (CITY AND STATE OR FOREIGN COUNTRY)




                                                                19d. BIRTHPLACE (CfTY, COUNTY AND STATE)




           .
           9
                                                                20d. BIRTHPLACE (CITY, COUNTY AND STATE)

           1,


                21a. CHILO CURRENT NAME. (FIRST MIDDf.E LAST SUfflX)


                               {mmldd/yyyy)
                21b. DATE. OF BIRTH             21C.5EX



                218. PRIOR NAME OF CHILD {FIRST MIDDLE LAST SUFFlX)- IF APPt.1CABLE




         WARNING: This Is a governmental document.       Texas Penal Code, Section 37.10, specifies pena
         entries or providing false information in this document.
                                                                VS-165   REV 0712017

   Texas Department of State HeaHh Selvlces. Vital Statistics                                                         VS-165 REV 0712017
                                                                                                                                            1
          A:)DITlONAL CHILDREN AFFECTED BY THIS SUIT FROM SECTION 3 IIF APPLICABLE)
     '  .       23a. CHILO CURRENT NAME (FIRST MIDDLE LAST SUFFIX)
    ~·

           ...
            ~
                                              I
                23b. CATE OF BIRTH {mmlddlyyyy)
                                                23c.SEX       I 23d. BfRTHPI.ACE (CITY, COUNTY AND STATE)

            Ii
                238. PRIOR NAME OF CHILD {FIRSTMfDDLE L.4STSUFFJX)-IF APPUCASLE.



                24a. CHILD CURRENT NAME (FIRST MIDDLE L.AST 81.JFRX)



           "'                                 I
                24b. CATE OF BIRTH (mm/ddyy)'y) 24c.SEX       124d. BIRTHPLACE (CITY,
                                                                                 COUNTYANDSTATE)

            ~   248. PRIOR NAME OF CHILD (FIRST MIDDLE LAST SUFRX)-IF APPUCABLE



                25a. CHILD CURRENT NAME (FIRST MIDDLE LAST SUFFIX)