Fill and Sign the New York Certificate Marriage Form

LOCAL INDEX NUMBER STATE FILE NUMBER New York State Department of Health CERTIFICATE OF DISSOLUTION OF MARRIAGEHU SB AN D 1. HUSBAND -- NAME: FIRST MIDDLE LAST                   1A. SOCIAL SECURITY NUMBER       2. DATE OF BIRTH 3. STATE OF BIRTH (COUNTRY IF NOT USA)       4.A RESIDENCE: STATE       4B. COUNTY       4C. LOCALITY (CHECK ONE AND SPECIFY) CITY OF       TOWN OF       VILLAGE OF      Month Day Year                   4D. STREET AND NUMBER OF RESIDENCE (INCLUDE ZIP CODE)             4E. IF CITY OR VILLAGE, IS RESIDENCE WITHIN CITY OR VILLAGE LIMITS YES NO IF NO, SPECIFY TOWN:       5A. ATTORNEY – NAME       5B. ADDRESS (INCLUDE ZIP CODE)             WIFE 6A. WIFE – NAME FIRST MIDDLE LAST                   6B. MAIDEN       6C. SOCIAL SECURITY NUMBER       7. DATE OF BIRTH 8. STATE OF BIRTH (COUNTRY IF NOT USA)       9.A RESIDENCE: STATE       9B. COUNTY       9C. LOCALITY (CHECK ONE AND SPECIFY) CITY OF       TOWN OF       VILLAGE OF      Month Day Year                   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:       10A. ATTORNEY - NAME       10B. ADDRESS (INCLUDE ZIP CODE)             11A. PLACE OF THIS MARRIAGE - CITY, TOWN OR VILLAGE       11B. COUNTY       11C. STATE (COUNTRY IF NOT USA)       12A. DATE OF THIS MARRIAGE Month Day Year 12B. APPROXIMATE DATE COUPLE SEPARATED       Month Year 13A. NUMBER OF CHILDREN EVER BORN ALIVE OF THIS MARRIAGE (SPECIFY)       13B. NUMBER OF CHILDREN UNDER 18 IN THIS FAMILY (SPECIFY)                                    DECREE 14A. I CERTIFY THAT A DECREE OF DISSOLUTION OF THE ABOVE MARRIAGE WAS RENDERED ON Month Day Year 14B. DATE OF ENTRY Month Day Year 14C. TYPE OF DECREE - DIVORCE, ANNULMENT, OTHER DISSOLUTION (SPECIFY)                                          14D. COUNTY OF DECREE       14E. TITLE OF COURT       14F. SIGNATURE OF COUNTY CLERK CONFIDENTIAL INFORMATION HUSBAND 15. RACE: WHITE, BLACK, AMERICAN INDIAN, OTHER (SPECIFY)       16. NUMBER OF THIS MARRIAGE - FIRST, SECOND, ETC. (SPECIFY)       17. IF PREVIOUSLY MARRIED HOW MANY ENDED BY 18. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY ELEMENTARY HIGH SCHOOL COLLEGE 0 1 2 3 4 5 6 7 8 1 2 3 4 1 2 3 4 5+ 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17A. DEATH NUMBER       NONE B. DIVORCE OR ANNULMENT NUMBER       NONE WIFE 19. RACE: WHITE, BLACK, AMERICAN INDIAN, OTHER (SPECIFY) 20. NUMBER OF THIS MARRIAGE – FIRST SECOND, ETC. (SPECIFY) 21. IF PREVIOUSLY MARRIED HOW MANY ENDED BY 18. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY ELEMENTARY HIGH SCHOOL COLLEGE 0 1 2 3 4 5 6 7 8 1 2 3 4 1 2 3 4 5+ 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17A. DEATH NUMBER       NONE B. DIVORCE OR ANNULMENT NUMBER       NONE 23. PLAINTIFF - HUSBAND, WIFE, OTHER (SPECIFY)       24. DECREE GRANTED TO HUSBAND, WIFE, OTHER (SPECIFY)       25. LEGAL GROUNDS FOR DECREE (SPECIFY)       26. SIGNATURE OF PERSON PREPARING CERTIFICATE ATTORNEY AT LAW NOTE: Social Security Numbers of the husband and wife 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 (5/2000)TYPE, OR PRINT IN PERMANENT BLACK INK