Form Vs-39m - Request For Copy Of Marriage Certificate printable pdf download

Form Vs-39m - Request For Copy Of Marriage Certificate

REQUEST FOR COPY OF MARRIAGE CERTIFICATE

VS-39M

Revised: 8/17/00

PLEASE PRINT

DO NOT MAIL CASH

FULL NAME

FIRST

MIDDLE

LAST

GROOM

FULL NAME BEFORE MARRIAGE

FIRST

MIDDLE

LAST

BRIDE

DATE OF MARRIAGE

PLACE OF MARRIAGE

( MONTH/DAY/YEAR)

TOWN

PLEASE NOTE: ONLY THE BRIDE AND GROOM APPEARING ON THE MARRIAGE CERTIFICATE SHALL RECEIVE A CERTIFIED

COPY OF SUCH CERTIFICATE INCLUDING THEIR SOCIAL SECURITY NUMBERS AS SPECIFIED IN PA 97-7.

ALL OTHER CERTIFIED COPIES WILL MASK THE SOCIAL SECURITY NUMBERS OF THE BRIDE AND GROOM TO COMPLY WITH

THE PROVISIONS OF PA 97-7.

PERSON MAKING THIS REQUEST:

NAME: ______________________________________________________________________________________________________________

FIRST

MIDDLE

LAST NAME

ADDRESS: ___________________________________________________________________________________________________________

NUMBER

STREET

TOWN/CITY: _____________________________________

STATE: ________________ZIP CODE: _____________________

_____________________________________________________________________________________________

SIGNATURE:

THE LEGAL FEE IS $5.00 PER COPY.

NUMBER OF COPIES WANTED:

_________________

AMOUNT ATTACHED:

$_________________________

FEE: $5.00 PER COPY MONEY ORDER MADE PAYABLE TO THE TOWN/CITY OF MARRIAGE

MAIL THIS REQUEST WITH PAYMENT TO THE TOWN CLERK AT THE TOWN/CITY OF MARRIAGE

FOR TOWN CLERK ADDRESSES PLEASE SEE ALPHABETICAL LISTING BY TOWN

Form Vs-39m - Request For Copy Of Marriage Certificate