Application for Certified Copy of Marriage Certificate - Kansas
APPLICATION
FOR
CERTIFIED
COPY
OF
KANSAS
MARRIAGE
CERTIFICATE
MARRlACE
CERTIFICATES
ARE
ON
FILE
FROM
MAY
1.19
13
TO
PRESENT
(PLEASE
PRINT)
$12.00
t;OK ONE
CERTIFIED
COPY
AND
$7.00
FOR
EACH
ADDITIONAl.
CERnFIED
COPY
OF
THE
SAME
RECORD
KllhlBEK
OF
CEK1'IFIC'-iTES
REULiESI'EU
FEE
1NFOR.WATION
ON
REVERSE
SIDE
CFRTIFIED
COI'ILS
--
TOTAL
FEE
DA'I'L
UI:
GROOM
--.
-
R
I
KTH
FIRST hllDTI1.E
LAST
MO
DAY
LK
BRIDE
B
1
K'TH
FIRST
MIDDLE
LAST
h10
DAY
YR
(MAll)l?N
OR
PREVIOUS
MAKI<1FI)
SIIRNAI\.lE)
D:ITLr:
OF
MiZKKIrlGE
hlcll\l-TI
I
DAY
Y
!.i,qI<
PLACE
IN
IV'I
IICH
k1ARRIAGE LICENSE
WAS
ISSUED
COUNTY
STATE
(11
lIS.1'
Bli
L-iKSAF\
CITY
IN
WHICH
MARRIAGE
TOOK
PLACE
YOU
MUST
INCLUDE
A
COPY
OF
PHOTO
ID
WITH
THIS
FORM
OR
TWO
ALTERNATIVE
DO-SEE
REVERIE
SIDE
FOR
LIST1
YOUR
M.4lLlNC;
AUUKESS
-
-
CITY
STATE
ZIP
CODE
KE!ZSON
FOR
REVLIEST
(PLEASE
BE
SPECIFIC)
(We
ask
(1115
so
that
wc
can
pruvtde
npprofr1:ttc
xrvicr:
lor
your
11ccds)
YOUK
UAk'l'IhlE
TEI
EPHONE
NUhlUER
k'OLlR
RE1,ATIOKSIiIP
'TO
PERSON
NAMED
ON
CERTIFICATE (REQUIRED)-
(See
rcvcrsc
side
f'or
elig~bll
~t
rcquirwnents)
YOUR
SIGNATURE
(REQUIRED)
-
TODAY'S
DATE
KANSAS
DEPJ
RTMENT
01:
HEALTH
AND
ENVIKONhlENT
CENI'EK
FOR
HEAI.TH
AND
BNVIRONMEKTAL
STATISTICS
hl.lILIKC
AIIDRESS:
OFFICE
OF
I'ITAI,
STATISI'ICS
1000 S\Y
JACKSON,
su
I-r~,
120
'I'OPEKA,
KS
16612-2221
\VALK-IN
CUSTOAIEK
SERVICE
HOllRS:
q.00
-
4:00,
MONDAY
-
FRIUAY
OFFICE
HOURS:
8:OU
-
f;:00,
MONDAY
-
FRIDAY,
PIIONE
(785)
296-1400
PLEASE
ENCLOSE
A
B
iJSINESLS
SIZE
SELF-ADDRESSED
STAM
PEU
ENVELOPE.
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