Fillable Printable Mail-in Application for Copy of Divorce Certificate
Fillable Printable Mail-in Application for Copy of Divorce Certificate
Mail-in Application for Copy of Divorce Certificate
DOH-4378 (7/11) Page 1 of 2
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Mail-in Application for Copy of Divorce Certificate
Information Page — Mail-in Application for Copy of Divorce Certificate
General Instructions
• Use this application if you are the wife, husband or spouse named on the divorce certificate.
• If you are not the wife, husband or spouse named on the certificate, then you must submit with this application a copy of a New York State
Court Order requiring the divorce certificate.
• Use this application only if the divorce was granted in New York State (including New York City) on or after January 1, 1963. Contact the
county clerk of the county where the divorce was granted if prior to January 1, 1963.
• Do not use this application for genealogy requests.
• If delivery is to a P.O. Box or to a third party you must submit, with this application, a notarized statement signed by the wife, husband or
spouse and a copy of the wife, husband or spouse's driver license.
• Print a copy of this application, complete and sign.
• Mail the application along with a check or money order and a copy of any required documentation (see below).
For regular handling send by first class mail, registered mail,
certified mail or U.S. Priority Mail to:
New York State Department of Health
Vital Records Certification Unit
P.O. Box 2602
Albany, NY 12220-2602
For priority handling (add $15.00 per copy ordered), submission by
overnight carrier is recommended. Send to:
New York State Department of Health
Vital Records Certification Unit
800 North Pearl Street - 2nd Floor
Menands, NY 12204
Who is eligible to obtain a divorce certificate copy?
• If the applicant is not the wife, husband or spouse, a New York State Court Order is required to obtain a copy of the divorce certificate.
• A copy of the New York State Court Order must be submitted along with the application if the request is being made by someone other than
the wife, husband or spouse on the record.
Identification Requirements -- Application must
be submitted with copies of either A or B:
Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for travel.
One (1) of the following forms of valid photo-ID:
• Driver license
• State Issued Non-Driver Photo-ID Card
• Passport
• U.S. Military Issued Photo-ID
-- OR --
Two (2) of the following showing the applicant's current name and address:
• Utility or telephone bills
• Letter from a government agency dated within the last six (6) months
Fees: If no record is on file, a No Record Certification is issued and the fee is not refunded.
• For regular handling: The fee is $30.00 per copy. — Total for one (1) copy is $30.00. Total for two (2) copies is $60.00, etc.
• For priority handling: The fee is $30.00 + $15.00 per copy — Total for one (1) copy is $45.00. Total for two (2) copies is $90.00, etc.
Submitting the application by overnight carrier is recommended. Completed requests will be returned by first class mail unless a pre-paid
return mailer for overnight delivery is provided with the request.
• Send check or money order payable to the New York State Department of Health. Do not send cash.
Note: Payment submitted from foreign countries must be made by a check drawn on a United States bank or by international money order.
Do not send cash.
Processing Time
• For the latest information on processing times, please visit our web page at www.health.ny.gov/vital_records/processingtime.htm
• For faster processing, you may wish to use your credit card and submit your request on-line or by telephone. For credit card fees and
ordering information visit our web page at www.health.ny.gov/vital_records/vitalchek.htm
Completing the Form
®
• If you are using Adobe Reader 7.0 or newer (available as a free download from www.adobe.com) you can fill in the form directly in Adobe
Reader by clicking on the appropriate space and entering the information (use the TAB key to move to the next field, shift-TAB to move
backwards). Print the completed form, sign and mail to the above address.
• You can print out a blank copy of the form and then type or print the required information.
• Be sure to sign the form before mailing and include a check or money order made payable to the New York State Department of Health
along with any required documentation.
DOH-4378 (7/11) Page 2 of 2
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section
Mail-in Application for Copy of Divorce Certificate
If you are not the wife, husband or spouse named in the Decree, you must submit copy of New York State Court Order.
Date Signed:
Month Day Year
Signature of Applicant:
Regular Handling
(Check Only One)
Priority Handling
$30.00 x
OR
$45.00 x Copies = $
Please print or type the name and address where record
should be sent:
(If delivery is to a P.O. Box or third party, you must submit
with this application a notarized statement signed by the applicant and a copy of
the applicant's driver license.)
Address of Applicant:
(Applicant's Name)
(Name)
(Street)
(Street)
(City) (State) (Zip)
Telephone No.: ( )
(City) (State) (Zip)
Required ID must be included with application. Make check or money order payable to New York State Department of Health.
For regular handling: Enclose $30 per copy or No Record Certification.
Send to:
New York State Department of Health
Vital Records Certification Unit
P.O. Box 2602
Albany, NY 12220-2602
For priority handling: Enclose $45 per copy or No Record Certification.
Submission by overnight carrier is recommended. Send to:
New York State Department of Health
Vital Records Certification Unit
800 North Pearl Street - 2nd Floor
Menands, NY 12204
Name:
Wife/Husband/Spouse
Address at Time of Decree:
Wife/Husband/Spouse
First Middle Last Birth Name (if different)
Town or City County
Divorce Certificate No.:
(if known)
Date of Final Decree or
Period Covered by Search:
Decree Issued on
or Search from:
In what capacity are you acting?:
(mm / dd / yyyy)
Search to:
(if searching period)
(mm / dd / yyyy)
What is your relationship to person whose record is required?
(If self, write "SELF".)
If attorney, give name and relationship of your client to person whose record is required:
Place Where Marriage License Was Issued:
Town or City County
Marriage and Divorce Information
Local Registration No.:
(if known)
Purpose for which record is required?
County in Which Divorce Decree Was Filed:
Date of Marriage:
4
Name:
Address at Time of Decree:
First Middle Last Birth Name (if different)
Town or City County
(mm / dd / yyyy)
