California Form Vs 12 PDF Details

In the State of California, the process of obtaining a certified copy of a fetal death record is governed by specific regulations and procedures, as outlined by the California Department of Public Health. These records, which have been meticulously maintained since July 1, 1905, serve not only as important documents for families needing to acknowledge and document the loss of a pregnancy but also as crucial pieces of information for medical and health-related research. The California VS 12 form plays a pivotal role in this process, guiding individuals through the steps required to request a certified copy of a fetal death record. Applicants are instructed to fill out the form with detailed information regarding the fetal death and the applicant's details to ensure accuracy and verification. A fee of $18 is required for each copy requested, establishing a financial component to the application process. Should the search for the requested record come up empty, the fee is retained by the department as a search charge, and a "Certificate of No Public Record" is issued, marking a transparent policy regarding unsuccessful searches. Additionally, the form emphasizes the necessity of submitting payment via check or money order, explicitly advising against sending cash to minimize the risk of loss or misdirection. This thorough procedure, encapsulated in the submission of the California VS 12 form, underscores the state's commitment to maintaining high standards of public health record-keeping and the sensitivity with which it approaches the documentation of fetal deaths.

QuestionAnswer
Form NameCalifornia Form Vs 12
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesprintable blank california death certificate, california death certificate form pdf, california death certificate form, california death certificate template

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State of California – Health and Human Services Agency

California Department of Public Health

APPLICATION FOR CERTIFIED COPY OF FETAL DEATH RECORD

INFORMATION:

Fetal death records have been maintained in the California Department of Public Health Vital Records since July 1, 1905.

INSTRUCTIONS:

1.Complete a separate application for each fetal death record requested.

2.Complete the Applicant Information section and provide your signature where indicated. In the Fetal Death Information section, provide all the information you have available to identify the fetal death record. If the information you furnish is incomplete or inaccurate, we may not be able to locate the record.

3.Submit $18 for each copy requested. If no fetal death record is found, the fee will be retained for searching the record (as required

by law) and a “Certificate of No Public Record” will be issued to the applicant. Indicate the number of copies you want and include the correct fee(s) in the form of a personal check or postal or bank money order (International Money Order for out‐of‐country requests) made payable to CDPH Vital Records. PLEASE SUBMIT CHECK OR MONEY ORDER ̶ DO NOT SEND CASH (CDPH cannot be held responsible for fees paid in cash that are lost, misdirected, or undelivered).

4.Mail completed applications with the fee(s) to:

California Department of Public Health

Vital Records ̶ MS 5103

P.O. Box 997410

Sacramento, CA 95899‐7410

(916) 445‐2684

Fee: $18 per copy (payable to CDPH Vital Records). PLEASE SUBMIT CHECK OR MONEY ORDER ̶ DO NOT SEND CASH

(CDPH cannot be held responsible for fees paid in cash that are lost, misdirected, or undelivered).

PLEASE ATTACH CHECK HERE

APPLICANT INFORMATION (PLEASE PRINT OR TYPE)

Today’s Date:

 

 

 

 

 

Agency Name (if applicable)

 

Agency Case Number

Inmate ID Number

 

 

 

 

Print Name of Applicant

 

Signature of Applicant

Purpose of Request

 

 

 

 

Mailing Address – Number, Street

Amount Enclosed – DO NOT SEND CASH

Number of Copies

$ ______ Check $_____ Money Order

City

State/Province

ZIP Code

 

 

Daytime Telephone (include area code)

Country

(

)

 

 

 

 

Name of Person Receiving Copies, if Different from Applicant

Mailing Address for Copies, if Different from Applicant

City

State

ZIP Code

 

 

 

FETAL DEATH INFORMATION (PLEASE PRINT OR TYPE)

Complete information below as shown on the fetal death record, to the best of your knowledge.

FETAL DEATH FIRST Name

MIDDLE Name

LAST Name

 

 

 

City of Fetal Death (must be in California)

 

County of Fetal Death

 

 

Date of Fetal Death – MM/DD/CCYY (If unknown, enter approximate date of fetal death)

Sex

 

 

_____Female _____Male

 

 

 

Father/Parent FIRST Name

MIDDLE Name

LAST Name (Before Marriage/Domestic Partnership)

Mother/Parent FIRST Name

MIDDLE Name

LAST Name (Before Marriage/Domestic Partnership)

FETAL DEATH

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VS 12 (01/14)

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california death certificate blank form conclusion process described (stage 1)

2. Right after filling out this section, go to the next stage and fill in all required particulars in these blank fields - City of Fetal Death must be in, Date of Fetal Death MMDDCCYY If, Sex Female Male, FatherParent FIRST Name, MIDDLE Name, LAST Name Before MarriageDomestic, MotherParent FIRST Name, MIDDLE Name, LAST Name Before MarriageDomestic, VS , and FETAL DEATH Page of .

Filling out part 2 of california death certificate blank form

Always be very mindful when filling out Date of Fetal Death MMDDCCYY If and FatherParent FIRST Name, because this is the part in which a lot of people make a few mistakes.

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