Form - DOH-2168 Certificate of Dissolution of Marriage

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LOCAL INDEX NUMBER

New York State

Department of Health

TYPE,OR CERTIFICATE OF DISSOLUTION OF MARRIAGE

STATE FILE NUMBER

PRINT IN PERMANENT

1A. NAME:

FIRST

MIDDLE

LAST

1B. BIRTH NAME, IF DIFFERENT 1C. SOCIAL SECURITY NUMBER

BLACK INK

2A. DATE OF BIRTH Month Day Year

2(CBO. SUTNATTREYOIFF NBOIRTTUHSA)

3. SEX (Optional)

4A. RESIDENCE: STATE

4B. COUNTY

4C. LOCALITY (CHECK ONE AND SPECIFY)

CITY OF

TOWN OF

VILLAGE OF

4

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/Husband/Spouse

Wife/Husband/Spouse

6A. NAME:

FIRST

MIDDLE

LAST

6B. BIRTH NAME, IF DIFFERENT 6C. SOCIAL SECURITY NUMBER

9

7A. DATE OF BIRTH Month Day Year

7(CBO. SUTNATTREYOIFF NBOIRTTUHSA)

8. SEX (Optional)

9A. RESIDENCE: STATE

9B. COUNTY

9C. LOCALITY (CHECK ONE AND SPECIFY)

CITY OF

TOWN OF

VILLAGE OF

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)

11

12A. DATE Month Day Year 12B. APPROXIMATE Month Year 13A. NUMBER OF CHILDREN EVER BORN 13B. NUMBER OF CHILDREN UNDER 18

OF THIS

DATE COUPLE

ALIVE OF THIS MARRIAGE (SPECIFY)

IN THIS FAMILY (SPECIFY)

MARRIAGE

SEPARATED

DECREE

14A. I CERTIFY THAT A DECREE OF Month Day Year 14B. DATE Month Day Year 14C. TYPE OF DECREE - DIVORCE, ANNULMENT, OTHER

DISSOLUTION OF THE ABOVE

OF

DISSOLUTION (SPECIFY)

15

MARRIAGE WAS RENDERED ON

ENTRY:

14D. COUNTY OF DECREE

14E. TITLE OF COURT

14F. SIGNATURE OF COUNTY CLERK

23

>

CONFIDENTIAL INFORMATION

Wife/Husband/ Wife/Husband/

Spouse

24

15. RACE: WHITE,

16. NUMBER OF THIS 17. IF PREVIOUSLY MARRIED

BLACK, AMERICAN MARRIAGE - FIRST,

HOW MANY ENDED BY

INDIAN, OTHER SECOND, ETC. (SPECIFY) A. DEATH

B. DIVORCE OR

(SPECIFY)

ANNULMENT

18. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY 0 1 2ELE3ME4NTA5RY6 7 8 H1IGH2SCH3 OO4L 1 C2OLL3EGE4 5+

NUMBER

NUMBER

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17

NONE

NONE

19. RACE: WHITE,

20. NUMBER OF THIS 21. IF PREVIOUSLY MARRIED

22. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY

BLACK, AMERICAN MARRIAGE - FIRST,

HOW MANY ENDED BY

25

INDIAN, OTHER (SPECIFY)

SECOND, ETC. (SPECIFY) A. DEATH

B. DIVORCE OR ANNULMENT

0 1 2ELE3ME4NTA5RY6 7 8 H1IGH2SCH3 OO4L 1 C2OLL3EGE4 5+

Spouse

QR

23. PLAINTIFF:

NUMBER

NUMBER

NONE

NONE

24. DECREE GRANTED TO:

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 25. LEGAL GROUNDS FOR DECREE (SPECIFY)

QS

26. SIGNATURE OF PERSON PREPARING CERTIFICATE

>

ATTORNEY AT LAW

NOTE: Social Security Numbers of the parties to the marriage 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 (7/2011)

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