Marriage License Request (PDF)

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. 
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 Check or Money Order made payable to the Waterford Town 
Clerk.
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.