Application to Town/City Clerk
for Copy of Marriage Certificate
TC-04
Donna Lent, Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
TC-04 (6/20) Page 2of 2
PLEASE COMPLETE FORM AND REMIT FEE
Required ID must be included with application (see attached instructions for additional information or visit
www.brookhavenny.gov/departments/townclerk). Make check or money order payable to Donna Lent, Brookhaven Town Clerk. Fee:
$10 per copy or No Record Certification. Please do not send cash or stamps. Enclose photocopy of required identification, self-
addressed stamped envelope and fee.
1. Name of Groom/Bride/Spouse:
2. Name of Bride/Groom/Spouse:
3. Birth Name of Groom/Bride/Spouse (if different): 4. Birth Name of Bride/Groom/Spouse (if different):
5. Groom/Bride/Spouse’s Date of Birth (or age at time of marriage): 6. Bride/Groom/Spouse’s Date of Birth (or age at time of marriage):
7. Residence of Groom/Bride/Spouse (at time of marriage):
8. Residence of Bride/Groom/Spouse (at time of marriage):
9. If Previously Married, State Name Used at that Time: 10. If Previously Married, State Name Used at that Time:
11. Place Where License was Issued:
12. Place Where Marriage was Performed:
13. Local Registration No. (if known): 14. Date of Marriage or Period Covered by Search:
15. For What Purpose is Information Required: 16. What is your relationship to person whose record is requested? If
Self, State “SELF”:
17. In what capacity are you acting: 18. If Attorney, Name and Relationship of Your Client to Persons Whose
Marriage Record is Required:
19. Signature of Applicant: 20. Date:
21. Phone Number: 22. No. of Copies Requested: 23. Amount Enclosed:
24. Address of Applicant: 25. N
ame and Address Where Record is to be Sent:
If you are not the bride, groom or spouse on the record, you must submit documentation of a judicial or other purpose.
