The marriage license shall have appended to it two certificates, numbered to correspond with the license (one marked original and one marked duplicate), which shall be in substantially the following form:
I hereby certify that on (date), at (city, borough or town), Pennsylvania, (name) and (name) were by me united in marriage, in accordance with license issued by the Court of Common Pleas of (name) numbered
Signed
(Title of person solemnizing marriage)
Address