THE VIRGIN ISLANDS OF THE UNITED STATES
THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS AND STATISTICS APPLICATION FOR CERTIFIED COPY OF DEATH RECORD Do Not Complete This Application Before Reading The Instructions And Information On The Back Of This Form PART A. TYPE OF CERTIFIED COPY REQUESTED: CHECK ONE: _______Death Verification Fee $6.00 _______Death Certificate Fee $15.00 A verification is an abstract from the death A certificate is an abstract from the death record record that gives the name and date of death. that gives the name, date of death, gender, place of death and cause of death. PART B. ELIGIBILITY: DEATH VERIFICATION Anyone may apply for a death verification. DEATH CERTIFICATE CHECK ONE: _______ I am a parent, legal guardian or sibling of the person listed on the record. _______ I am a party entitled to receive the record as a result of a court order. _______ I am an attorney representing the estate of the person listed on the record. _______ I can establish that the record is needed for settlement of estate, entitled benefits, or other proper purpose. PART C. …
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THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS AND STATISTICS APPLICATION FOR CERTIFIED COPY OF DEATH RECORD Do Not Complete This Application Before Reading The Instructions And Information On The Back Of This Form PART A. TYPE OF CERTIFIED COPY REQUESTED: CHECK ONE: _______Death Verification Fee $6.00 _______Death Certificate Fee $15.00 A verification is an abstract from the death A certificate is an abstract from the death record record that gives the name and date of death. that gives the name, date of death, gender, place of death and cause of death. PART B. ELIGIBILITY: DEATH VERIFICATION Anyone may apply for a death verification. DEATH CERTIFICATE CHECK ONE: _______ I am a parent, legal guardian or sibling of the person listed on the record. _______ I am a party entitled to receive the record as a result of a court order. _______ I am an attorney representing the estate of the person listed on the record. _______ I can establish that the record is needed for settlement of estate, entitled benefits, or other proper purpose. PART C. DISTRICT APPLYING TO: CHECK ONE - St. Croix District St. Thomas/St. John District PART D. DEATH RECORD INFORMATION: First Name on Record Middle Name on Record Last Name on Record Date of Death – mm/dd/yy Place of Death (City and Island) Sex of Decedent: Mother’s / Parent’s Name Father’s / Parent’s Name PART E. APPLICANT INFORMATION: Applicant’s First Name Applicant’s Middle Name Applicant’s Last Name Applicant’s Mailing Address State City Zip Code Type of Photo Id Photo Id# Relationship to Person on Record Purpose for Which Record is Requested Number of Copies Amount Enclosed Money Order ID # PART F. MAIL COPY OF RECORD TO: (ONLY COMPLETE THIS SECTION IF FORWARDING ADDRESS IS DIFFERENT FROM APPLICANT’S MAILING ADDRESS) First Name Middle Name Last Name Mailing Address State City Zip Code ( )___________ Signature of Applicant Physical Address Date Telephone # Do Not Complete Below Unless In The Presence Of A Notary Public Sworn To And Subscribed Before Me This __________ Day Of __________________ _______. WITNESS My Hand And Official Seal. Day Month Year (Notary Public’s Signature) INSTRUCTIONS Please submit the following: 1. Completed, notarized application TO THE DISTRICT WHERE THE DEATH OCCURRED. Virgin Islands Department of Health Virgin Islands Department of Health St. Thomas/St. John District or St. Croix District Office of Vital Records and Statistics Office of Vital Records and Statistics 1303 Hospital Ground, Suite 10 3500 Estate Richmond St. Thomas, VI 00802. St. Croix, VI 00820. 2. Photocopy of your valid picture identification document such as your driver’s license, passport card, military identification card, permanent resident card, TWIC card, valid voter’s card, state issued identification card, or senior citizen’s card. 3. Supporting documents are needed to verify the reason record is requested. 4. Certified copy of court/appointment document if applying as legal representative or legal guardian. 5. United States Postal Money Order in the amount of $15.00, made payable to the Virgin Islands Department of Health. (NO PERSONAL CHECKS WILL BE ACCEPTED) 6. A returned stamped envelope must be sent with the application and must have the returned address to return the Death Certificate(s). SEE POSTAL CARRIER FOR RATES (U.S. PRIORITY OR EXPRESS MAIL, FEDEX, DHL, UPS) 7. Submittal of an incomplete application will delay processing. 8. If a record is not found, a certified “No Record Found” letter will be issued. 9. If an application is incomplete and applicant is unreachable by phone, a “Missing Information” letter will be issued. It is very important to provide all required information on the application. CONTACT INFORMATION Virgin Islands Department of Health Virgin Islands Department of Health Virgin Islands Department of Health Office of Vital Records and Statistics Office of Vital Records and Statistics Office of Vital Records and Statistics St. Thomas, VI St. Croix, VI St. John, VI Tel#: (340) 774-9000 Cel#: (340) 643-6302 Tel#: (340) 776-6400 Tel#: (340) 718-1311 Tel#: (340) 712-0117/(340) 712-0119 Ext. 6014 Ext. 4685/4681/4683 (340) 712-0116 or (340) 712-0118 Tel#: (340) 715-5116 or (340) 715-51177