LOCAL INDEX NUMBER TYPE , OR PRINT IN BLACK INK Wife/Husband/Spouse PERMANENT 1A. NAME: New York State Department of Health CERTIFICATE OF DISSOLUTION OF MARRIAGE FIRST MIDDLE LAST 2B. STATE OF BIRTH (COUNTRY IF NOT USA) 3. SEX (Optional) 4A. RESIDENCE: STATE STATE FILE NUMBER 1B. BIRTH NAME, IF DIFFERENT 1C. SOCIAL SECURITY NUMBER 4C. LOCALITY (CHECK ONE AND SPECIFY) CITY OF TOWN OF VILLAGE OF 2A. DATE OF BIRTH Month Day Year 4B. COUNTY 4 4D. STREET AND NUMBER OF RESIDENCE (INCLUDE ZIP CODE) 5A. ATTORNEY - NAME 6A. NAME: FIRST MIDDLE 8. SEX (Optional) LAST 9A. RESIDENCE: STATE 4E. IF CITY OR VILLAGE, IS RESIDENCE WITHIN CITY OR VILLAGE LIMITS? YES NO IF NO, SPECIFY TOWN: 5B. ADDRESS (INCLUDE ZIP CODE) 6B. BIRTH NAME, IF DIFFERENT 6C. SOCIAL SECURITY NUMBER 9B. COUNTY 9C. LOCALITY (CHECK ONE AND SPECIFY) CITY OF TOWN OF VILLAGE OF 9 Wife/Husband/Spouse 7A. DATE OF BIRTH Month Day Year 7B. STATE OF BIRTH (COUNTRY IF NOT USA) 9D. STREET AND NUMBER OF RESIDENCE (INCLUDE ZIP CODE) 10A. ATTORNEY - NAME 11A. PLACE OF THIS MARRIAGE - CITY, TOWN OR VILLAGE 11B. COUNTY Month Year 9E. IF CITY OR VILLAGE, IS RESIDENCE WITHIN CITY OR VILLAGE LIMITS? YES NO IF NO, SPECIFY TOWN: 10B. ADDRESS (INCLUDE ZIP CODE) 11C. STATE (COUNTRY IF NOT USA) 13A. NUMBER OF CHILDREN EVER BORN ALIVE OF THIS MARRIAGE (SPECIFY) Day Year 13B. NUMBER OF CHILDREN UNDER 18 IN THIS FAMILY (SPECIFY) 11 12A. DATE OF THIS MARRIAGE Month Day Year 12B. APPROXIMATE DATE COUPLE SEPARATED Month Day DECREE 15 14A. I CERTIFY THAT A DECREE OF DISSOLUTION OF THE ABOVE MARRIAGE WAS RENDERED ON 14D. COUNTY OF DECREE 14F. SIGNATURE OF COUNTY CLERK Year 14B. DATE Month OF ENTRY: 14E. TITLE OF COURT 14C. TYPE OF DECREE - DIVORCE, ANNULMENT, OTHER DISSOLUTION (SPECIFY) 23 > CONFIDENTIAL INFORMATION Spouse 24 Wife/Husband/ Wife/Husband/ 15. RACE: WHITE, 16. NUMBER OF THIS 17. IF PREVIOUSLY MARRIED MARRIAGE - FIRST, HOW MANY ENDED BY BLACK, AMERICAN SECOND, ETC. (SPECIFY) A. DEATH INDIAN, OTHER B. DIVORCE OR (SPECIFY) ANNULMENT NUMBER NUMBER NONE NONE 19. RACE: WHITE, 20. NUMBER OF THIS 21. IF PREVIOUSLY MARRIED BLACK, AMERICAN MARRIAGE - FIRST, HOW MANY ENDED BY INDIAN, OTHER SECOND, ETC. (SPECIFY) A. DEATH B. DIVORCE OR (SPECIFY) ANNULMENT NUMBER NUMBER NONE NONE 24. DECREE GRANTED TO: 18. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY 0 1 2 ELEMENTARY 3456 7 8 HIGH SCHOOL 1234 09 10 11 12 1 COLLEGE 2 3 4 5+ 00 01 02 03 04 05 06 07 08 13 14 15 16 17 22. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY 0 1 2 ELEMENTARY 3456 7 8 HIGH SCHOOL 1234 09 10 11 12 1 COLLEGE 2 3 4 5+ Spouse 25 00 01 02 03 04 05 06 07 08 13 14 15 16 17 QR QS 23. PLAINTIFF: 25. LEGAL GROUNDS FOR DECREE (SPECIFY) 26. SIGNATURE OF PERSON PREPARING CERTIFICATE > ATTORNEY AT LAW DOH-2168 (7/2011) 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. American LegalNet, Inc. www.FormsWorkFlow.com