MISSISSIPPI VITAL RECORDS

P.O. Box 1700

Jackson, MS 39215-1700

APPLICATION FOR CERTIFIED COPY OF STATISTICAL RECORD OF MARRIAGE

INFORMATION ABOUT BRIDE AND GROOM WHOSE STATISTICAL RECORD OF MARRIAGE IS
REQUESTED (Please Print)

1. Full Name of Groom (First, Middle, Last Name)

___________________________________________________________

2. Full Name of Bride (First, Middle, Last Name)

___________________________________________________________

3. Date of Marriage: Month __________Day __________ Year _______

3. Place of Marriage: County ___________________

City or Town _______________________________ State ___________

5. Where License was Bought: County ___________________

City or Town _______________________________ State ___________

PERSON REQUESTING CERTIFIED COPY

6. Purpose for which Copy is to be Used

____________________________________________________________

7. Relationship or Interest of Person Requesting Certificate

____________________________________________________________

8. Fee

I am Enclosing a Fee of $___________ for ___________ Certified Copies.

9. Signature of Applicant ______________________________________

10. Date Signed _______________

Print Your Mailing Address Here

11. ________________________________________________________ Name

12. ________________________________________ APT. NO.________Street or Route

13. ________________________________________________________ City or Town, State, Zipcode