Fillable Printable Mail-in Application for Copy of Marriage Certificate - New York

Mail-in Application for Copy of Marriage Certificate - New York

New York State Department of Health

Vital Records Section

Mail-in Application for Copy of

Marriage Certificate

Information Page ù Mail-in Application for Copy of Marriage Certificate

General Instructions

ò Do not use this application to submit your requestby fax.

Use this application if you are the bride or groom named on the marriage certificate.

If you are not the bride or groom named on the marriage certificate, then you mustsubmit with this application a

copy of documentation establishing a judicial or other proper purpose (see below).

Use thisapplication only if the marriage license wasobtained in New York State outside of New York City.Do not

use this application if the marriage license was obtained in any of the five (5) boroughs of New York City.

ò Do not use this application forgenealogy requests.

If delivery is to a P.O.Box or to athird party youmust submit, with thisapplication, anotarized statementsigned by

the bride or groom and a copy of the bride or groom's driver's license.

ò Print a copy of this application, complete and sign.

ò Mail application with check or money order and a copy of any required documentation (see below) to:

For regular handling send by first class mail, registered

mail, certified mail or U.S. Priority Mail to:

For priorityhandling (add $15.00 per copy ordered) send

by U.S. Postal Express or other overnight carrieronly to:

Certification Unit

Vital Records Section

New York State Department of Health

P.O. Box 2602

Albany, NY 12220-2602

Certification Unit

Vital Records Section / 2nd Floor

New York State Department of Health

800 North Pearl Street

Menands, NY 12204

What is a judicial or other proper purpose?

òIf the applicantis not the bride or groom,a judicial or other properpurpose must be documented. An example of a

judicial or other proper purpose would be a marriage record needed by the applicant to claim a benefit.

ò Documentation would consistof a copy of a court order or an official letter verifying that a copy ofthe requested

marriage record is required from the applicant in order to process a claim.

Fees: If no record is on file, aNo Record Certification will be issued and the fee isnot refunded.

For regular handling:The fee is $30.00 per copy.ù Total for one (1) copy is $30.00. Total for two (2) copies is

$60.00, etc.

For priority handling: The feeis $30.00 + $15.00 per copy ù Total for one (1) copy is $45.00. Total fortwo (2)

copies is $90.00, etc. Please send the application by overnight carrier to ensure priority handling.

ò Send check or money order payable to the New York State Department of Health. Do not send cash.

Note:

Payment submitted from foreign countries mustbe made by a check drawn on a United States bank or by

international money order.Do not send cash.

Processing Time

òUp to two (2) weeks when ordered with priority handling and submitted by overnight carrier.

òA minimum of eight (8) to ten (10) weeks when ordered without priority handling.

For faster processing, you may wish to use your credit card and submit your request by e-mail, fax, or telephone.

Completing the Form

If you are using Acrobat Reader 5.0 (available as a free download from www.adobe.com) you can fill in the form

directly in AcrobatReader 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.

ò 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-301B(p) (09/2003)

New York State Department of Health

Vital Records Section

Mail-in Application for Copy of

Marriage Certificate

Please complete, sign, and mail with check or money order.

You may enter the required information directly into this PDF document (see instruction sheet for details) and print out a

copy ready for signature, or print out a blank copy andprint or typethe required information before signing.

Name of Groom (as recorded on marriage license):Groom's Date of Birth:

(or age at time of marriage)

First Middle Last

(mm / dd / yyyy)

Name of Bride (as recorded on marriage license):Bride's Date of Birth:

(or age at time of marriage)

First Middle Maiden Last

(mm / dd / yyyy)

If Bride Was Previously Married, State Name Used at that Time:Marriage Certificate No.:

(if known)

First Middle Last

Residence of Groom:

Place Where License Was Issued:Local Registration No.:

(if known)

Town or City County

County State

Residence of Bride: Place Where Marriage Was Performed:Date of Marriage or Period

Covered by Search:

County State Town or City County

Married on or

Search from:

Purpose for which record is required: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, state "SELF".)

If attorney, give name and relationship of your client to person whose record is required:

Submit documentation of a judicial or other proper purpose, if you are not the bride or groom.

Date Signed:

Month Day Year

Signature of Applicant:

Regular Handling

(Check Only One)

Priority Handling

$30.00 x

$45.00 xCopies =$

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 drivers license.)

Address of Applicant:

(Applicant's Name)

(Name)

(Street)

(City)(State)(Zip)

Telephone No.: ()

(City)(State)(Zip)

DOH-301B(p) (09/2003)