Form Doh-4378 - New York State Department Of Health Page 2
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1
2NEW YORK STATE DEPARTMENT OF HEALTH
Mail-in Application for Copy of Divorce Certificate
Vital Records Section
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.
For priority handling: Enclose $45 per copy or No Record Certification.
Send to:
Submission by overnight carrier is recommended. Send to:
New York State Department of Health
New York State Department of Health
Vital Records Certification Unit
Vital Records Certification Unit
P.O. Box 2602
800 North Pearl Street - 2nd Floor
Albany, NY 12220-2602
Menands, NY 12204
Wife/Husband/Spouse
Name:
First
Middle
Last
Birth Name (if different)
Address at Time of Decree:
Town or City
County
Wife/Husband/Spouse
Name:
First
Middle
Last
Birth Name (if different)
Address at Time of Decree:
Town or City
County
Marriage and Divorce Information
Date of Marriage:
Local Registration No.:
Date of Final Decree or
Place Where Marriage License Was Issued:
(if known)
Period Covered by Search:
(mm / dd / yyyy)
Town or City
County
Purpose for which record is required?
Divorce Certificate No.:
Decree Issued on
(if known)
or Search from:
(mm / dd / yyyy)
County in Which Divorce Decree Was Filed:
In what capacity are you acting?:
Search to:
(mm / dd / yyyy)
(if searching period)
What is your relationship to person whose record is required?
If attorney, give name and relationship of your client to person whose record is required:
(If self, write "SELF".)
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:
Signature of Applicant:
Regular Handling
$30.00 x
Month
Day
Year
OR
(Check Only One)
Priority Handling
$45.00 x
Copies
=
$
4
Please print or type the name and address where record
should be sent:
Address of Applicant:
(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.)
(Applicant's Name)
(Name)
(Street)
(Street)
(City)
(State)
(Zip)
Telephone No.: (
)
(City)
(State)
(Zip)
DOH-4378 (7/11) Page 2 of 2
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