DH 1959, 01/2022, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)
Florida Department of Health
Bureau of Vital Statistics
www.floridahealth.gov/certificates
AFFIDAVIT TO RELEASE CAUSE OF DEATH INFORMATION
ATTENTION: This form must be completed in the presence of a Notary Public
If you are entitled to receive the death certificate with cause of death, this form may be used to authorize another person to obtain
the certificate. This form is intended for single use only and must contain original signatures. This form must be accompanied by
Application for Florida Death Certificate form (DH 727).
My name is: _____________________________________________. I am eligible, by law, to obtain the
(Eligible person completing affidavit to release)
death certificate with cause for ________________________________ because I am the: (check one)
(Decedent named on death certificate)
____
Surviving spouse listed on the death certificate
____
Parent(s) listed on the death certificate
____
____
Child of the decedent (Must be 18 years or older)
Grandchild of the decedent (Must be 18 years or older)
____
Sibling of the decedent (Must be 18 years or older)
____
Legal representative of an eligible person listed above (Documentation Required)
I authorize the Florida Department of Health, Bureau of Vital Statistics to issue the death certificate with cause to:
_______________________________________________.
(Name of person to receive death certificate)
A copy of a valid photo ID for both the eligible person authorizing release and the person receiving the death
certificate is required and must be attached to this form (see list on reverse side).
Pursuant to s. 382.026, Florida Statutes, any person who willfully and knowingly makes any false statement in a certificate,
record, or report required by this chapter, or in an application for an amendment thereof, or in an application for a certified copy
of a vital record, or who willfully and knowingly supplies false information, intending that such information be used in the
preparation of any such report, record, or certificate, or amendment thereof, commits a felony of the third degree, punishable as
provided in s. 775.082, F.S., s. 775.083, F.S., or s. 775.084, F.S.
I hereby declare under oath that the above statements are true and correct. ____________________________________________.
(Signature of eligible person completing affidavit to release)
STATE OF FLORIDA COUNTY OF __________________________
Sworn to (or affirmed) and subscribed before me by means of ______ physical presence or ______ online notarization, this
______ day of _______________________, 20____ , by __________________________________________. (Name of Affiant)
_____________________________________________ _____________________________________
Signature of Notary Public Printed Name of Notary Public
Stamp Commissioned Name of Notary Public
Personally Known_______ OR Produced Identification_________
Type of Identification Produced_____________________________________
Even if personally known to the notary, the rules of the Florida Department of Health require both the eligible person
completing the affidavit to release and the person receiving the death certificate to provide a copy of valid photo
identification.
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DH 1959, 01/2022, Florida Administrative Code Rule 64V-1.0131 (Obsoletes Previous Editions)
INFORMATION AND INSTRUCTIONS FOR AFFIDAVIT TO RELEASE
CAUSE OF DEATH INFORMATION
If you need assistance, please contact our Vital Records Section at 904-359-6900 ext. 9000
If you are entitled to the death certificate with cause of death, this form may be used to authorize another person to
obtain the certificate. This form is intended for single use only and must contain original signatures. This form must
be accompanied by the Application for Florida Death Certificate form (DH 727) completed by the applicant (person
to receive death certificate). Form DH 727 may be downloaded from our website.
ELIGIBILITY (Section 382.025, Florida Statutes):
CAUSE OF DEATH INFORMATION: Death records less than 50 years old with the cause of death information
included may only be issued to:
1. The decedent’s spouse or parent
2. The decedent’s child, grandchild or sibling, if of legal age
All requests for a death certificate that includes the cause of death information must state the qualifying eligibility or
be accompanied with a notarized Affidavit to Release Cause of Death Information form (DH 1959) signed by an
eligible person (form is available on our website) and a copy of valid photo identification of both the person
authorizing release and the applicant.
If funeral home is requesting cause of death and is not representing an eligible person or not the funeral home of
record, a completed Affidavit to Release Cause of Death Information form (DH 1959) must accompany the
application.
ACCEPTABLE FORMS OF IDENTIFICATION: Driver License, State Identification Card, Passport,
Military Identification Card. A foreign issued driver license, identification card, consular card, or Matricula card
require two additional forms of identification, such as a vehicle title or registration, health insurance card,
employment ID, school ID, tax document, or mail with current address.
FLORIDA DEPARTMENT OF HEALTH
BUREAU OF VITAL STATISTICS
ATTN: VITAL RECORDS SECTION
P.O. BOX 210
JACKSONVILLE, FL 32231-0042
Street Address: 1217 North Pearl Street, Jacksonville, Florida, 32202
PLEASE VISIT OUR WEBSITE:
www.floridahealth.gov/certificates
