Form REG-3 "Delegation of Authority to Receive Certified Copy of Vital Record (Marriage/Civil Union)" - New Jersey (English/Spanish)

Form REG-3 or the "Delegation Of Authority To Receive Certified Copy Of Vital Record (marriage/civil Union) (english/spanish)" is a form issued by the New Jersey Department of Health.

Download a PDF version of the Form REG-3 down below or find it on the New Jersey Department of Health Forms website.

ADVERTISEMENT

Download Form REG-3 "Delegation of Authority to Receive Certified Copy of Vital Record (Marriage/Civil Union)" - New Jersey (English/Spanish)

1498 times
Rate
(4.8 / 5) 75 votes
New Jersey Department of Health
Office of Vital Statistics and Registry
P.O. Box 370
Trenton, NJ 08625-0370
DELEGATION OF AUTHORITY TO RECEIVE CERTIFIED COPY OF VITAL RECORD
(FOR MARRIAGE / CIVIL UNION RECORDS)
DELEGACIÓN DE AUTORIDAD PARA RECIBIR UNA COPIA CERTIFICADA DE UN REGISTRO CIVIL
(PARA REGISTROS DE MATRIMONIO / UNIÓN CIVIL)
This statement must be signed and dated in the presence of a Notary Public. Authorized individual must also provide valid
identification.
Este documento debe ser firmado y fechado ante un notario público. El individuo autorizado también debe proveer prueba de identificación
valida.
Full Name of Authorizing Person
Relationship to Individual on Record
(Nombre Completo de la Personal Autorizante)
(Relación con el Individuo en Registro)
I give written authorization to:
(Yo otorgo autorizacion por escrito a:)
Name of Authorized Individual
(Nombre de Individuo Autorizado)
who will obtain certified copies of vital records on my behalf. The information of the requested record is as follows:
(quien obtendrá copias certificadas del registro civil en mi nombre. La información del registro is la siguiente:)
Full Name of Spouse A/Partner A (List name given at birth or on birth certificate/Maiden name) (Print or Type)
[Nombre Completo de Pareja A (Inscrito en el acta de nacimiento o nombre de soltera)]
First
Middle
Last
(Primer)
(Segundo)
(Apellido)
Full Name of Spouse B/Partner B (List name given at birth or on birth certificate/Maiden name) (Print or Type)
[Nombre Completo de Pareja B (Inscrito en el acta de nacimiento o nombre de soltera)]
First
Middle
Last
(Primer)
(Segundo)
(Apellido)
Exact Date of Event (MM/DD/YYYY)
(Fecha Exacta del Evento) (Mes/Día/Año)
Location of Event (City and County)
(Lugar del Evento) (Ciudad y Condado)
Signature of Authorizing Person
Date
(Firma de la Personal Autorizante)
(Fecha)
X
Sworn to before me on this ________________ day of ____________________________, 20______.
Signature of Notary Public: ___________________________________________________________
____________________________________
(Stamp)
REG-3
NOV 16
New Jersey Department of Health
Office of Vital Statistics and Registry
P.O. Box 370
Trenton, NJ 08625-0370
DELEGATION OF AUTHORITY TO RECEIVE CERTIFIED COPY OF VITAL RECORD
(FOR MARRIAGE / CIVIL UNION RECORDS)
DELEGACIÓN DE AUTORIDAD PARA RECIBIR UNA COPIA CERTIFICADA DE UN REGISTRO CIVIL
(PARA REGISTROS DE MATRIMONIO / UNIÓN CIVIL)
This statement must be signed and dated in the presence of a Notary Public. Authorized individual must also provide valid
identification.
Este documento debe ser firmado y fechado ante un notario público. El individuo autorizado también debe proveer prueba de identificación
valida.
Full Name of Authorizing Person
Relationship to Individual on Record
(Nombre Completo de la Personal Autorizante)
(Relación con el Individuo en Registro)
I give written authorization to:
(Yo otorgo autorizacion por escrito a:)
Name of Authorized Individual
(Nombre de Individuo Autorizado)
who will obtain certified copies of vital records on my behalf. The information of the requested record is as follows:
(quien obtendrá copias certificadas del registro civil en mi nombre. La información del registro is la siguiente:)
Full Name of Spouse A/Partner A (List name given at birth or on birth certificate/Maiden name) (Print or Type)
[Nombre Completo de Pareja A (Inscrito en el acta de nacimiento o nombre de soltera)]
First
Middle
Last
(Primer)
(Segundo)
(Apellido)
Full Name of Spouse B/Partner B (List name given at birth or on birth certificate/Maiden name) (Print or Type)
[Nombre Completo de Pareja B (Inscrito en el acta de nacimiento o nombre de soltera)]
First
Middle
Last
(Primer)
(Segundo)
(Apellido)
Exact Date of Event (MM/DD/YYYY)
(Fecha Exacta del Evento) (Mes/Día/Año)
Location of Event (City and County)
(Lugar del Evento) (Ciudad y Condado)
Signature of Authorizing Person
Date
(Firma de la Personal Autorizante)
(Fecha)
X
Sworn to before me on this ________________ day of ____________________________, 20______.
Signature of Notary Public: ___________________________________________________________
____________________________________
(Stamp)
REG-3
NOV 16
ADVERTISEMENT