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: ¾ Death Verification Fee $6.00 ¾ Death Certificate Fee $15.00 A verification is an abstract from the death A certificate is an abstract from the death record that gives the name and date of death.. record 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: ¾ I am a parent, legal guardian or sibling of the person listed on the record. ¾ I am a party entitled to receive the record as a result of a court order. ¾ I am an attorney representing the estate of the person listed on the record. ¾ 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 - ¾ St. …
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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: ¾ Death Verification Fee $6.00 ¾ Death Certificate Fee $15.00 A verification is an abstract from the death A certificate is an abstract from the death record that gives the name and date of death.. record 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: ¾ I am a parent, legal guardian or sibling of the person listed on the record. ¾ I am a party entitled to receive the record as a result of a court order. ¾ I am an attorney representing the estate of the person listed on the record. ¾ 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 - ¾ St. Croix District ¾ St. Thomas/St. John District PART D. DEATH RECORD INFORMATION: ( ) Signature Of Applicant Physical Address Date Telephone # Do Not Complete Below Unless In The Presence Of A Notary Public First Name On Record Middle Name On Record Last Name On Record Date Of Death – mm/dd/yy Place Of Death (City And Island) Father’s Name Mother’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 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 reason record is requested. 4. Certified copy of court/appointment document if applying as legal representative or legal guardian. 5. Person given permission from person listed on the record (must provide notarized statement by person on record or authorized applicant). 6. 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) 7. A returned stamped envelope must be sent with the application and must have the returned address to return the Death Certificate(s). 8. Submittal of an incomplete application will delay processing. 9. If a record is not found, a certified “No Record Found” letter will be issued. 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 Tel#: (340) 718-1311 Tel#: (340) 776-6400 Ext. 4686/4685/4683 Ext. 3846/3827/3688/3622/3687 Ext. 6014 Cell#: (340) 643-6302 10. 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. (U.S. PRIORITY OR EXPRESS MAIL, FEDEX, DHL, UPS) SEE POSTAL CARRIER FOR RATES