Form - DOH-2168 Certificate of Dissolution of …

1 LOCAL INDEX NUMBERSTATE FILE NUMBERNew York StateDepartment of HealthTYPE , ORPRINT INPERMANENTBLACK INKCERTIFICATE OF Dissolution OF MARRIAGE1C. SOCIAL SECURITY NUMBER2A. DATE OF BIRTH2B. STATE OF BIRTH4A. RESIDENCE: STATE4B. COUNTY4C. LOCALITY (CHECK ONE AND SPECIFY)(COUNTRY IF NOT USA)CITY OFTOWN OFVILLAGE OF4E. IF CITY OR VILLAGE, IS RESIDENCE WITHIN CITY OR VILLAGE LIMITS?4D. STREET AND NUMBER OF RESIDENCE (INCLUDE ZIP CODE)YESNO4IF NO, SPECIFY TOWN:Wife/Husband/Spouse5A. ATTORNEY - NAME5B. ADDRESS (INCLUDE ZIP CODE)6A. NAME:FIRSTMIDDLELAST6B. BIRTH NAME, IF DIFFERENT6C. SOCIAL SECURITY NUMBER99D. STREET AND NUMBER OF RESIDENCE (INCLUDE ZIP CODE)9E. IF CITY OR VILLAGE, IS RESIDENCE WITHIN CITY OR VILLAGE LIMITS?

2 YESNOIF NO, SPECIFY TOWN:10B. ADDRESS (INCLUDE ZIP CODE)10A. ATTORNEY - NAME11A. PLACE OF THIS marriage - CITY, TOWN OR VILLAGE11B. COUNTY11C. STATE (COUNTRY IF NOT USA)11 APPROXIMATEDATE COUPLESEPARATEDNUMBER OF CHILDREN EVER BORNALIVE OF THIS marriage (SPECIFY)13B. NUMBER OF CHILDREN UNDER 18IN THIS FAMILY (SPECIFY)12A. DATE OF THISMARRIAGEM onthDayYear12B.

3 MonthYear13A.

4 14A. MonthDayYear14B. DATEM onthDayYear14C. I CERTIFY THAT A DECREE OFDISSOLUTION OF THE ABOVE marriage WAS RENDERED ONTYPE OF DECREE - DIVORCE, ANNULMENT, OTHERDISSOLUTION (SPECIFY)OFENTRY: 1514D. COUNTY OF DECREE14E. TITLE OF COURTDECREE14F.

5 SIGNATURE OF COUNTY CLERK23>CONFIDENTIAL INFORMATION15. RACE: WHITE, BLACK, AMERICAN INDIAN, OTHER (SPECIFY)16. NUMBER OF THISMARRIAGE - FIRST,17. IF PREVIOUSLY MARRIEDHOW MANY ENDED BY18. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLY24 SECOND, ETC. (SPECIFY)ELEMENTARYHIGH SCHOOL COLLEGEA. DEATHB. DIVORCE ORANNULMENT012345678123412345+0102030405 06070810111214151617 NUMBERNUMBER000913 NONENONERACE: WHITE, BLACK, AMERICAN INDIAN, OTHER (SPECIFY)NUMBER OF THISMARRIAGE - FIRST,IF PREVIOUSLY MARRIEDHOW MANY ENDED BY19. 20. 21. 22. EDUCATION: INDICATE HIGHEST GRADE COMPLETED ONLYSECOND, ETC. (SPECIFY)ELEMENTARYHIGH SCHOOL COLLEGEA. DEATHB. 25 DIVORCE ORANNULMENT012345678123412345+0102030405 06070810111214151617000913 NUMBER NUMBER

6 NONENONE23. PLAINTIFF:24. DECREE GRANTED TO:25. LEGAL GROUNDS FOR DECREE (SPECIFY)QR26. SIGNATURE OF PERSON PREPARING CERTIFICATEQS>ATTORNEY AT LAWNOTE: Social Security Numbers of the parties to the marriage are mandatory.

7 They are required by New York State Public Health Law Section 4139 and 42 666(a). They may be used for child support enforcement (7/2011)Wife/Husband/Spouse1A. NAME:FIRSTMIDDLELAST1B. BIRTH NAME, IF DIFFERENTWife/Husband/SpouseWife/Husband /Spouse3. SEX (Optional)7A. DATE OF BIRTH9A. RESIDENCE: STATE9B. COUNTY9C. LOCALITY (CHECK ONE AND SPECIFY)MonthCITY OFTOWN OFVILLAGE OFDayYearMonthDayYear7B.

8 STATE OF BIRTH(COUNTRY IF NOT USA)8. SEX (Optional)