New York State Marriage Certificate Request Form Check One: __Search & Certification ($5) __Search & Certified Copy ($5) Name of Groom (first/middle/last):______________________________________ Residence of Groom (county/state):______________________________________ Maiden Name of Bride (first/middle/last):_______________________________ Residence of Bride (county/state):______________________________________ If Bride Previously Married, Name Used at That Time:____________________ Age or Date of Birth: Groom:__________________ Bride:___________________ Place Where License Was Issued:_________________________________________ Place Where Marriage Was Performed:_____________________________________ Date of Marriage or Period Covered by Search:___________________________ Purpose for Which Record Is Required:___________________________________ Your relationship to person whose record is requested (if self, state "self"): ________________________________________________________________________ In what capacity are you acting?________________________________________ If attorney, name and relationship of your client to persons whose record is required: Client:_________________________ Relationship:______________________ Signature of Applicant:__________________________ Date:_________________ Street:_________________________________________________________________ City:__________________________ State:____________________ Zip:_________ Please PRINT name and address where record should be sent: Name:___________________________________________________________________ Street:_________________________________________________________________ City:__________________________ State:__________________ Zip:__________