Form 502 - Application For Certified Copy Of Statistical Record Of Marriage - 1993
ADVERTISEMENT
1MISSISSIPPI VITAL RECORDS
P.O. Box 1700
Jackson, MS 39215-1700
APPLICATION FOR CERTIFIED COPY OF STATISTICAL RECORD OF MARRIAGE
INFORMATION
1. Marriage records have been kept by state and county officials since January 1, 1926. From July 1, 1938, to
December 31, 1941, records were kept only by the circuit court clerk in the county in which the marriage license
was issued.
2. The fee for a search of the records and a certified copy is $10.00. Additional copies ordered at the same time are
$2.00 each.
3. A five year search of our records will be made. If the record is not on file, a search fee of $6.00 will be retained.
INSTRUCTIONS
1. Complete the required sections of this form. PLEASE PRINT.
2. The application must be signed.
3. PAYMENT:
Out-of-state:
Remit a bank or postal money order or a bank cashier’s check in the correct amount made
payable to Mississippi State Department of Health.
Mississippi Resident:
In addition to the above methods of payment, personal checks are acceptable if drawn on
a Mississippi bank; make payable to Mississippi State Department of Health.
We accept no responsibility for cash sent through the mail. Request for adjustments or refunds will be honored
only if received within six months of application.
4.
Send completed application, appropriate fee and self-addressed stamped legal size envelope to the address at the
top of this form.
INFORMATION ABOUT BRIDE AND GROOM WHOSE STATISTICAL RECORD OF MARRIAGE IS REQUESTED (Please
Print)
FIRST NAME
MIDDLE NAME
LAST NAME
1. FULL NAME
OF GROOM
FIRST NAME
MIDDLE NAME
LAST NAME
2. FULL NAME
OF BRIDE
MONTH
DAY
YEAR
3. DATE OF
MARRIAGE
COUNTY
CITY OR TOWN
STATE
4. PLACE OF
MARRIAGE
COUNTY
CITY OR TOWN
STATE
5. WHERE LICENSE
WAS BOUGHT
PERSON REQUESTING CERTIFIED COPY
6. PURPOSE FOR WHICH COPY IS TO BE USED
7. RELATIONSHIP OR INTEREST OF PERSON REQUESTING CERTIFICATE
8. FEE
I AM ENCLOSING A FEE OF $___________ FOR ___________ CERTIFIED COPIES.
9. SIGNATURE OF APPLICANT
10.
DATE SIGNED
PRINT YOUR MAILING ADDRESS HERE
Name
11.
APT. NO.
Street or Route
12.
City or Town
13.
State, ZIP code
Mississippi State Department of Health
Revised 9-93
Form No. 502
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal