Louisiana Vital Records Registry Form Page 2

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LOUISIANA VITAL RECORDS REGISTRY
In compliance with Louisiana Statutes, Title 40:41, “Disclosure of Records,” please
complete this Records Release Authorization Form.
This is to authorize you to release the (birth)(death) record of:
_______________________________________________ (Full Name)
_______________________________________________ (Date of Event)
Your relationship to this person:
_______________________________________________________________________
To the following named agency/individual:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Signature of: _________________________________________________________________
(Registrant, if 18 years of age or older)
_________________________________________________________________
(Parent or legal guardian, if registrant is under 18)
_________________________________________________________________
Street Address
_________________________________________________________________
City/State/ZIP Code
_ (___________) ____________ - ______________________________________
Telephone number where you can be contacted for verification.
IF LEGAL GUARDIAN, PLEASE SUBMIT COPY OF CUSTODY PAPERS PLEASE
RETURN THIS RELEASE WITH THE ATTACHED TO EXPEDITE SERVICE.
(VRR_053)

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