THE VIRGIN ISLANDS OF THE UNITED STATES
THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS AND STATISTICS AFFIDAVIT FOR RELEASE OF CERTIFIED COPY OF BIRTH RECORD Before the undersigned, an officer duly commissioned by the laws of the United States Virgin Islands, on this _________ day of ________________________________ ___________, (Day) (Month) (Year) personally appeared ________________________________________________ , Printed Name of Affiant who having been first duly sworn and deposed says: CHECK ONE: ¾ I am the person listed on the record and am at least 18 years. ¾ I am a parent or legal guardian of the minor person listed on the record. ¾ I am a party entitled to receive the record as a result of a court order or power of attorney. ¾ I am an attorney representing the person listed on the record. …
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THE VIRGIN ISLANDS OF THE UNITED STATES DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS AND STATISTICS AFFIDAVIT FOR RELEASE OF CERTIFIED COPY OF BIRTH RECORD Before the undersigned, an officer duly commissioned by the laws of the United States Virgin Islands, on this _________ day of ________________________________ ___________, (Day) (Month) (Year) personally appeared ________________________________________________ , Printed Name of Affiant who having been first duly sworn and deposed says: CHECK ONE: ¾ I am the person listed on the record and am at least 18 years. ¾ I am a parent or legal guardian of the minor person listed on the record. ¾ I am a party entitled to receive the record as a result of a court order or power of attorney. ¾ I am an attorney representing the person listed on the record. I authorize the Office of Vital Statistics to issue a certified copy of the : CHECK ONE: ¾ Birth Verification ¾ Birth Certificate Of __________________________________________________________________________ (Name Of Person On Birth Record) To __________________________________________________________________________. (Name Of Person To Receive Copy Of Birth Record) I have attached the required photocopy of my valid picture id: __________________________________________________ ______________________ . (Type of Id Attached) Id# I hereby swear or affirm the above statements are true and correct. ________________ (Signature of Affiant) Sworn To And Subscribed Before Me This ______ Day Of ________________ ______. WITNESS My Hand And Official Seal. Day Month Year ______________________________ (Notary Public’s Signature)