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)