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DOH-4382 (7/11) Page 1 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Mail-in Application for Copy of Marriage Certificate Information Page — Mail-in Application for Copy of Marriage Certificate General Instructions • Use this application if you are the bride, groom or spouse named on the marriage certificate. • If you are not the bride, groom or spouse named on the marriage certificate, then you must submit with this application a copy of documentation establishing a judicial or other proper purpose (see below). • Use this application only if the marriage license was obtained in New York State outside of New York City. Do not use this application if the marriage license was obtained in any of the five boroughs of New York City. • Do not use this application for genealogy requests. • If delivery is to a P.O. Box or to a third party you must submit, with this application, a notarized statement signed by the bride, groom or spouse and a copy of the bride, groom or spouse's driver license. • Print a copy of this application, complete and sign. • Mail application with check or money order and a copy of any required documentation (see below). For regular handling send by first class mail, registered mail, certified mail or U.S. Priority Mail to: New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 avel. For priority handling (add $15.00 per copy ordered), submission by overnight carrier is recommended. Send to: New York State Department of Health Vital Records Certification Unit 800 North Pearl Street - 2nd Floor Menands, NY 12204 What is a judicial or other proper purpose? • If the applicant is not the bride, groom or spouse, a judicial or other proper purpose must be documented. An example of a judicial or other proper purpose would be a marriage record needed by the applicant to claim a benefit. • Documentation would consist of a copy of a court order or an official letter verifying that a copy of the requested marriage record is required from the applicant in order to process a claim. Identification Requirements Application must be submitted with copies of either A or B: Note: Copy of Passport required if request is made from a foreign country that requires a U.S. Passport for tr A. One of the following forms of valid photo-ID: • Driver license • State Issued Non-Driver Photo-ID Card • Passport • U.S. Military Issued Photo-ID OR B. Two of the following showing the applicant's current name and address: • Utility or telephone bills • Letter from a government agency dated within the last six months Fees: If no record is on file, a No Record Certification is issued and the fee is not refunded. • For regular handling: The fee is $30.00 per copy. — Total for one copy is $30.00. Total for two copies is $60.00, etc. • For priority handling: The fee is $30.00 + $15.00 per copy — Total for one copy is $45.00. Total for two copies is $90.00, etc. Submitting the application by overnight carrier is recommended. Completed requests will be returned by first class mail unless a pre-paid return mailer for overnight delivery is provided with the request. • Send check or money order payable to the New York State Department of Health. Do not send cash. Note: Payment submitted from foreign countries must be made by a check drawn on a United States bank or by international money order. Do not send cash. Processing Time • For the latest information on processing times, please visit our web page at www.health.ny.gov/vital_records/processingtime.htm • For faster processing, you may wish to use your credit card and submit your request on-line or by telephone. For credit card fees and ordering information visit our web page at www.health.ny.gov/vital_records/vitalchek.htm Completing the Form • If you are using Adobe Reader 7. ® 0 or newer (available as a free download from www.adobe.com) you can fill in the form directly in Adobe Reader by clicking on the appropriate space and entering the information (use the TAB key to move to the next field, shift-TAB to move backwards). Print the completed form, sign and mail to the above address. • You can print out a blank copy of the form and then type or print the required information. • Be sure to sign the form before mailing and include a check or money order made payable to the New York State Department of Health along with any required documentation. ---PAGE BREAK--- DOH-4382 (7/11) Page 2 of 2 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Mail-in Application for Copy of Marriage Certificate x OR x = $ 4 ( ) 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. Send to: New York State Department of Health Vital Records Certification Unit P.O. Box 2602 Albany, NY 12220-2602 For priority handling: Enclose $45 per copy or No Record Certification. Submission by overnight carrier is recommended. Send to: New York State Department of Health Vital Records Certification Unit 800 North Pearl Street - 2nd Floor Menands, NY 12204 Bride/Groom/Spouse Name (as recorded on marriage license): First Middle Last Birth Name (if different) Date of Birth: (or age at time of marriage) If Previously Married, State Name Used at that Time: First Middle Last Residence (at time of marriage): County State Bride/Groom/Spouse Name (as recorded on marriage license): First Middle Last Birth Name (if different) Date of Birth: (or age at time of marriage) If Previously Married, State Name Used at that Time: First Middle Last Residence (at time of marriage): County State Marriage Information Place Where Marriage License Was Issued: Town or City County Place Where Marriage Was Performed: Town or City County Marriage Certificate No.: (if known) Local Registration No.: (if known) Purpose for which record is required: In what capacity are you acting?: What is your relationship to person whose record is required? (If self, state "SELF".) Date of Marriage or Period Covered by Search: Married on or Search from: (mm / dd / yyyy) Search to: (if searching period) (mm / dd / yyyy) If attorney, give name and relationship of your client to person whose record is required: If you are not the bride, groom or spouse on the record, you must submit documentation of a judicial or other proper purpose. Date Signed: Signature of Applicant: Month Day Year Address of Applicant: (Applicant's Name) (Street) (City) (State) (Zip) Telephone No.: (Check Only One) Priority Handling $45.00 Regular Handling $30.00 Copies Please print or type the name and address where record should be sent: (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.) (Name) (Street) (City) (State) (Zip)