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STATE OF HAWAII, DEPARTMENT OF HEALTH OFFICE OF HEALTH STATUS MONITORING
REQUEST FOR CERTIFIED COPY OF
RECORD =$ =$ =$ 10.00
FIRST CERTIFIED COPY ADDITIONAL COPIES AT $4.00 EACH OTHER:_______________________ TOTAL COPIES
TOTAL AMOUNT DUE
GROOM'S NAME: FIRST BRIDE'S NAME: MONTH DATE OF MARRIAGE: CITY OR TOWN PLACE OF MARRIAGE: RELATIONSHIP OF REQUESTOR TO PERSON NAMED ON CERTIFICATE REASON FOR THIS REQUEST ISLAND DAY YEAR MIDDLE LAST
SIGNATURE OF REQUESTOR:
Don't Forget To Sign Here After Printing This Form
TELEPHONE NUMBERS RES:
PRINT NAME OF REQUESTOR: BUS: ADDRESS OF REQUESTOR: NO. AND STREET OR P.O. BOX
IF MAILING TO A LOCATION OTHER THAN ABOVE, PLEASE FILL THIS SECTION.
IF THE INFORMATION GIVEN IS INCORRECT, THE CERTIFICATE WILL FAIL TO REACH THE DESTINATION.
NAME OF PERSON TO RECEIVE CERTIFICATE
AGENCY OR ORGANIZATION
NUMBER AND STREET OR P.O. BOX
FOR OFFICE USE ONLY
NR FILE PENDING:
INDEX SEARCHED TO
VOLUMES SEARCHED TO
DATE COPY PREPARED
OHSM 137 (Rev. 9/13/05)
* Be sure to sign the "Signature of Requestor" Box before submitting this form.
After a request is submitted. All fees are non-refundable. SUBMIT THE COMPLETED REQUEST FORM: 1. Do not send payment in cash. 1250 Punchbowl Street. 2. PERSONAL CHECKS NOT ACCEPTED. 4. 2. Personal checks will not be accepted . By postal mail to: State Department of Health Office of Health Status Monitoring Vital Records Issuance Section PO Box 3378 Honolulu. additional copies require a new request.ONCE A REQUEST IS SUBMITTED: 1. money order. Hawaii 96801 All fees must be prepaid. 3. Honolulu 7:45 AM to 2:30 PM. Only one name is allowed on the request form. If a vital record is not found. In-person at: Room 103. Monday through Friday (Except Holidays) Payment of fees must be made by cash. all fees will be retained to cover the cost of the search. or cashier's check. Enclose a money order or cashier's check for the exact amount of fees made payable to: Hawaii State Department of Health.