Form Doh-4382 - Mail-In Application For Copy Of Marriage Certificate Page 2
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2NEW YORK STATE DEPARTMENT OF HEALTH
Mail-in Application for Copy of Marriage 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 Section / Certification Unit
Vital Records Section / Certification Unit
P.O. Box 2602
800 North Pearl Street - 2nd Floor
Albany, NY 12220-2602
Menands, NY 12204
Name of Groom (as recorded on marriage license):
Grooms Date of Birth:
(or age at time of marriage)
First
Middle
Last
(mm / dd / yyyy)
Name of Bride (as recorded on marriage license):
Brides 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
Purpose for which record is required: In what capacity are you acting?:
Search from:
(mm / dd / yyyy)
Search to:
(if searching period)
(mm / dd / yyyy)
What is your relationship to person whose
If attorney, give name and relationship of your client to person whose record is required:
record is required? (If self, state "SELF".)
Submit documentation of a judicial or other proper purpose, if you are not the bride or groom.
Date Signed:
Signature of Applicant:
Month
Day
Year
Regular Handling
$30.00 x
OR
(Check Only One)
Priority Handling
$45.00 x
Copies
=
$
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 applicants drivers license.)
(Applicants Name)
(Name)
(Street)
(Street)
(City)
(State)
(Zip)
Telephone No.: (
)
(City)
(State)
(Zip)
DOH-4382 (12/05) Page 2 of 2
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