New York State Department Of Health Certificate Of Dissolution Of Marriage

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STATE FILE NUMBER
LOCAL INDEX NUMBER
New York State
Department of Health
CERTIFICATE OF DISSOLUTION OF MARRIAGE
TYPE , OR
PRINT IN
1C. SOCIAL SECURITY NUMBER
1A. NAME:
FIRST
MIDDLE
LAST
1B. BIRTH NAME, IF DIFFERENT
P
ERMANENT
BLACK INK
3. SEX
2A. DATE OF BIRTH
2B. STATE OF BIRTH
4A. RESIDENCE: STATE
4B. COUNTY
4C. LOCALITY (CHECK ONE AND SPECIFY)
(COUNTRY IF NOT USA)
(Optional)
Month Day
Year
CITY OF
TOWN OF
VILLAGE OF
4D. STREET AND NUMBER OF RESIDENCE (INCLUDE ZIP CODE)
4E. IF CITY OR VILLAGE, IS RESIDENCE WITHIN CITY OR VILLAGE LIMITS?
4
YES
NO
IF NO, SPECIFY TOWN:
5A. ATTORNEY - NAME
5B. ADDRESS (INCLUDE ZIP CODE)
6A. NAME:
FIRST
MIDDLE
LAST
6B. BIRTH NAME, IF DIFFERENT 6C. SOCIAL SECURITY NUMBER
9
8. SEX
7A. DATE OF BIRTH
9A. RESIDENCE: STATE
9B. COUNTY
9C. LOCALITY (CHECK ONE AND SPECIFY)
7B. STATE OF BIRTH
(COUNTRY IF NOT USA)
(Optional)
Month
Day
Year
CITY OF
TOWN OF
VILLAGE OF
9D. STREET AND NUMBER OF RESIDENCE (INCLUDE ZIP CODE)
9E. IF CITY OR VILLAGE, IS RESIDENCE WITHIN CITY OR VILLAGE LIMITS?
YES
NO
IF NO, SPECIFY TOWN:
10B. ADDRESS (INCLUDE ZIP CODE)
10A. ATTORNEY - NAME
11A. PLACE OF THIS MARRIAGE - CITY, TOWN OR VILLAGE
11B. COUNTY
11C. STATE (COUNTRY IF NOT USA)
11
12A. DATE
Month
Day
Year
12B.
APPROXIMATE
Month
Year
13A.
NUMBER OF CHILDREN EVER BORN
13B. NUMBER OF CHILDREN UNDER 18
OF THIS
DATE COUPLE
ALIVE OF THIS MARRIAGE (SPECIFY)
IN THIS FAMILY (SPECIFY)
MARRIAGE
SEPARATED
14A.
I CERTIFY THAT A DECREE OF
14B. DATE
14C.
TYPE OF DECREE - DIVORCE, ANNULMENT, OTHER
Month
Day
Year
Month
Day
Year
DISSOLUTION OF THE ABOVE
OF
DISSOLUTION (SPECIFY)
MARRIAGE WAS RENDERED ON
ENTRY:
15
14D. COUNTY OF DECREE
14E. TITLE OF COURT
14F. SIGNATURE OF COUNTY CLERK
>
23
CONFIDENTIAL INFORMATION
15. RACE: WHITE,
16. NUMBER OF THIS
17. IF PREVIOUSLY MARRIED
18. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY
24
BLACK, AMERICAN
MARRIAGE - FIRST,
HOW MANY ENDED BY
ELEMENTARY
HIGH SCHOOL
COLLEGE
SECOND, ETC. (SPECIFY)
INDIAN, OTHER
A. DEATH
B. DIVORCE OR
0 1 2 3 4 5 6 7 8
1 2 3 4
1 2 3 4 5+
(SPECIFY)
ANNULMENT
01 02 03 04 05 06 07 08
10 11 12
14 15 16 17
NUMBER
NUMBER
00
09
13
NONE
NONE
19.
RACE: WHITE,
20.
NUMBER OF THIS
21.
IF PREVIOUSLY MARRIED
22. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY
BLACK, AMERICAN
MARRIAGE - FIRST,
HOW MANY ENDED BY
25
INDIAN, OTHER
SECOND, ETC. (SPECIFY)
A. DEATH
B.
DIVORCE OR
ELEMENTARY
HIGH SCHOOL
COLLEGE
0 1 2 3 4 5 6 7 8
1 2 3 4
1 2 3 4 5+
(SPECIFY)
ANNULMENT
00
01 02 03 04 05 06 07 08
09
10 11 12
13
14 15 16 17
NUMBER
NUMBER
NONE
NONE
23. PLAINTIFF:
24. DECREE GRANTED TO:
25. LEGAL GROUNDS FOR DECREE (SPECIFY)
QR
26. SIGNATURE OF PERSON PREPARING CERTIFICATE
QS
>
ATTORNEY AT LAW
NOTE: Social Security Numbers of the parties to the marriage are mandatory. They are required by New York
State Public Health Law Section 4139 and 42 U.S.C. 666(a). They may be used for child support
enforcement purposes.
DOH-2168 (7/2011)

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