Form Dh 1959 - Affidavit To Release Cause Of Death Information
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2AFFIDAVIT TO RELEASE CAUSE OF DEATH INFORMATION
ATTENTION: This form must be completed in the presence of a Notary Public
State of: _________________________
County of: _________________________
AFFIDAVIT TO RELEASE CAUSE OF DEATH INFORMATION
Pursuant to section 382.025, Florida Statute, Death Certificates with cause of death information may only be issued to the
decedent’s spouse, parent, or to the decedent’s child, grandchild, or sibling, if of legal age (18),
or to any person who provides a
will, insurance policy, or other document that demonstrates his or her interest in the estate of the decedent, or to any person who
provides documentation that he or she is acting on behalf of the above-stated persons.
NOTE: To obtain and use a Florida death record under false or fraudulent purposes, commits a felony of the third degree,
punishable as provided in Chapter 775, Florida Statutes.
BEFORE ME, the undersigned authority, personally appeared ____________________________________________
(Print name of person giving an affidavit) (1)
who after being duly sworn and deposes:
My name is __________________________________. I am authorized by law to receive the death certificate including
(Print name of person giving an affidavit) (2)
cause of death information of ________________________________. I am the (check applicable box):
(Print Decedent’s Full Name) (3)
____
Surviving spouse listed on the death certificate
____
Parent(s) listed on the death certificate
____
Child of the decedent
____
Sibling of the decedent
____
Legal representative of one of the above named. Enclose copy of legal representation.
____
Other: Specify: __________________________ Enclose copy of legal representation.
I hereby authorize the Department of Health, Office of Vital Statistics to issue the death certificate with cause of death of:
________________________________________ to ______________________________________________________________
(Print decedent’s full name) (4)
(Print name of person authorized to receive death certificate with cause of death included) (5)
FURTHER AFFIANT SAYETH NAUGHT
I hereby swear or affirm the above statements are true and correct.
____________________________________________________________________
Signature of person authorized to release death certificate with cause of death (6)
Subscribed and sworn before me this ________ day of ____________________, 20____ by
_________________________________, who is: __ personally known to me, or, __ who has produced
(Print name of Authorized Individual) (7)
_________________________ as identification. My commission expires: ____________________.
(Type of identification produced)
_________________________
_____________________________
(Signature of notary)
(Print, type or stamp name of notary)
(SEAL)
Even if personally known to the notary, the rules of the Department of Health require the person completing this form to provide
a photocopy of valid photo identification.
DH 1959, 08/2010, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)
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