USVI Public Records

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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 DEATH 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 a parent, sibling or legal guardian 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. I authorize the Office of Vital Statistics to issue a certified copy of the : CHECK ONE: ¾ Death Verification ¾ Death Certificate Of __________________________________________________________________________ (Name Of Person On Death Record) To __________________________________________________________________________. (Name Of Person To Receive Copy Of Death 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)