Affidavit for Correction of Marriage RecordNEW YORK STATE DEPARTMENT OF HEALTH Affidavit for Correction of Marriage Record
Vtal Records Section
FOR OFFICIAL USE ONLY
STATE OF
State File #
SS: District # Local Register #
COUNTY OF
Date Completed:
1. Names:
(Bride/Groom/Spouse -First Middle Current Surname Birth Name, if Different)
(Bride/Groom/Spouse -First Middle Current Surname Birth Name, !f Different)
2. Address:
(Street Address) (State) (Zip Code)
3. Marriage License 4. Date of Marriage:
issued by CityRown:
5. List Items to Be Corrected:
Item Number As It DOES Appear (list exactly) As It SHOULD Appear (list exactly)
6. Documentation Submitted:
7. Explanation fOr Errors: (Explanation must specifically address how and why each error occurred. Vague or incomplete answers will not be interpreted in your favor.)
Under penalty of perjury, I do hereby swear or affinn that the statements made herein are true and correct to the best of my knowledge and belief.
This affidavit with supporting documentation is being made for the purpose of having the record of maniage show the true facts and this affidavit will
become a permanent record. The mamage record is filed with the State of New York.
Signature
Subscribed and sworn to
Signature
(affirmed) before me this day of
Notary Public ~
DOH-1827 (7/2011) Page 1 of 2
NEW YORK STATE DEPARTMENT OF HEALTH Affidavit for Correction of Marriage Record
Vtal Records Section
INSTRUCTIONS
1. Affidavit for Correction of Marriage Record must be signed by both parties to the marriage in the
presence of a notary public, except in cases of divorce or death. Certified copy of divorce or
death must be submitted with affidavit.
2. The document required for correction of name, date of birth, place of birth and parents shown on
the marriage record must be a Birth Certificate with a raised seal. The document required for
those foreign born must be a birth certificate with certified translation, valid passport (if
photocopied all pages must be copied that have valid entries), U.S. Resident Alien Card or U.S.
Naturalization Certificate.
The document required for correction to change date of marriage and/or place of marriage must
be a letter from the officiant on official letterhead or a certrfied copy of the officiant's record or, for
a religious ceremony, a Church Certificate with Seal.
3. To process the correction and provide certified copies of the marriage record, the town or city
clerk or Department of Health shall be entitled to a fee not exceeding ten dollars to be fixed in the
case of town clerks by the town board, and in the case of city clerks by the common council or
governing body of such city.
Town or City Clerk:
Mail original affidavit and documentation along with a copy of the annotated and/or corrected
record to:
New York State Department of Health
Vital Records Section
Marriage Correction Unit
P.O. Box 2602
Albany, NY 12220-2602
DOH-1827 (7/2011) Page 2 of 2