Request for a Certified Copy of Marriage Record from the Town/City Vital Records
VS-39M Revised: 9/10/2009
Mail this request to the Town Vital Records office. For the address and phone number of Town
Vital Record offices in Connecticut, please refer to our website at www.ct.gov/dph.com.
PLEASE PRINT DO NOT MAIL CASH
Groom/Spouse
Full Legal Name Before Marriage
First Middle Last
Bride/Spouse
Full Legal Name Before Marriage
First Middle Last
Date of Marriage * (Month/Day/Year))
Town of Marriage
PLEASE NOTE: In accordance with C.G.S. §7-51A, only the bride, groom or spouse listed on the marriage certificate or other persons
authorized by the Department of Public Health, shall be issued a certified copy of a marriage certificate containing the Social Security
numbers of the bride, groom or spouse. All other requesters will receive a certified copy of the marriage certificate without the social
security numbers.
PERSON MAKING THIS REQUEST:
Name:
___________________________________________________________________________________________________________
First Middle Last Name
Address:
___________________________________________________________________________________________________________
Number Street
Town/City: _________________________ State: _______________________ Zip Code: __________
Telephone No.: _______________________ E-Mail Address: (optional): ___________________________
Relation to Person Named in Certificate: _________________________________________________
Signature: ____________________________________________________________________________
The fee for a copy of Marriage Certificate at the State or Town is $20.00 per copy.
Number of Copies Requested: _________________ Amount Enclosed: $_________________________
FEE: $20.00 PER COPY. Remit a Postal Money Order made payable to the City/Town
(Personal Checks are not accepted)
Mail this request to the City/Town (for town contact information, refer to our website at www.ct.gov/dph).
*
Note: Copies of death or marriage certificates for events that occurred less than 4 months prior to the date of the request
should be sent to the Vital Records office in the town of the event. Refer to our website at
www.ct.gov/dph for town contact
information.
