Record No............of Year........
THIS IS TO CERTIFY
that ................................................................. ,
first name, premarriage middle and surname, new middle and/or surname (if applicable)
residing at .......................................................... ,
who was born on ........................., at ........................ ,
date
and .................................................................. ,
first name, premarriage middle and surname, new middle and/or surname (if applicable)
residing at .......................................................... ,
who was born ........................, at ............................ ,
date
were married on.......................at ............................. ,
date
as shown by the duly registered license and certificate of marriage of said persons on file in this office.
(SEAL) ......................................
Town or City Clerk
Dated at.................., N. Y.
.................................
No other facts contained in the affidavits, statements, consents or licenses shall be certified by such town and city clerks, unless expressly requested in writing by the man or woman named in such affidavit, license, statement or record.
To effectuate such correction and provide certified copies of the amended certificate, the town or city clerk 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. The clerk shall forward a copy of such amended certificate to the commissioner of health.
N.Y. Dom. Rel. Law § 14-A