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Get Certificate Of Dissolution Of Marriage Ny

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

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