Request For A Certified Copy Of Marriage Record From The Town/city Vital Records
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1Marriage
Town/City
Request for a Certified Copy of
Record from the
Vital Records
VS-39M Revised: 9/10/2009
Mail this request to the Town Vital Records office. For the address and phone number of Town
Vital Record offices in Connecticut, please refer to our website at
PLEASE PRINT
DO NOT MAIL CASH
Full Legal Name Before Marriage
First
Middle
Last
Groom/Spouse
Full Legal Name Before Marriage
Bride/Spouse
First
Middle
Last
Date of Marriage *
Town of Marriage
(Month/Day/Year))
PLEASE NOTE: In accordance with C.G.S. §7-51A, only the bride, groom or spouse listed on the marriage certificate or other persons
authorized by the Department of Public Health, shall be issued a certified copy of a marriage certificate containing the Social Security
numbers of the bride, groom or spouse.
All other requesters will receive a certified copy of the marriage certificate without the social
security numbers.
PERSON MAKING THIS REQUEST:
Name:
___________________________________________________________________________________________________________
First
Middle
Last Name
Address:
___________________________________________________________________________________________________________
Number
Street
Town/City: _________________________ State: _______________________ Zip Code: __________
Telephone No.: _______________________ E-Mail Address: (optional): ___________________________
Relation to Person Named in Certificate: _________________________________________________
Signature: ____________________________________________________________________________
The fee for a copy of Marriage Certificate at the State or Town is $20.00 per copy.
Number of Copies Requested:
Amount Enclosed: $_________________________
_________________
City/Town
FEE: $20.00 PER COPY. Remit a Postal Money Order made payable to the
(Personal Checks are not accepted)
Mail this request to the City/Town (for town contact information, refer to our website at
).
*
Note: Copies of death or marriage certificates for events that occurred less than 4 months prior to the date of the request
should be sent to the Vital Records office in the town of the event. Refer to our website at
for town contact
information.
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