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Get NY DOH-2168 2000

BER 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 7. DATE OF BIRTH Day Month Year WIFE 4C. LOCALITY (CHECK ONE AND SPECIFY) CITY OF TOWN OF VILLAGE OF 4D. STREET AND NUMBER OF RESIDENCE (INCLUDE ZIP CODE) 9 STATE FILE NUMBER New York State Department of Health CERTIFICATE OF DISSOLUTION OF MARRIAGE 5B. ADDRESS (INCLUDE ZIP CODE) FIRST MIDDLE 8. STATE OF BIRT.

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