Application to Town/City Clerk
for Copy of Marriage Certificate
Donna Lent, Town Clerk TC-04 Supplement B
Patricia Ryan, Chief Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
TC-04 Supplement B (1/14) Page 1of 1
Notarized Authorization for a Third-Party to Obtain a Marriage Certificate
I, _______________________, hereby authorize ___________________________ to
obtain _____ copy(ies) of the following marriage certificate:
Groom’s Name: _____________________________
Bride’s Name: _____________________________
Place of Marriage: _____________________________
Date of Marriage: _____________________________
Reason Needed: _____________________________
___________________________ _________________
Signed Phone 1Xmber
___________________________
Date
STATE OF ___________________
COUNTY OF _________________
On the _____ day of _______________ in the year ________, before me, the undersigned, personally
appeared ______________________ proved to me on the basis of satisfactory evidence to be the
individual whose name is subscribed to the within instrument and acknowledge that he executed the same
in his capacity, and that by his signature on the instrument, the individual, or the person upon behalf of
which the individual acted, executed the instrument.
_______________________________
Notary Public
