The Department of Health and Hospitals Office of Public Health Vital Records Registry has developed a crucial document for families experiencing the profound loss of a stillbirth, known as the Phs520D form. This application enables them to officially request a Birth Resulting in Stillbirth Certificate, providing documented recognition of their child’s birth. Revised in September 2007, the form outlines a straightforward process for submission, which includes completing the application, including a state-issued photo ID, and enclosing the appropriate fees via check or money order to the Vital Records Registry in New Orleans, Louisiana. Importantly, the form clarifies that no fees are required for the initial certificate, while additional copies are available for a nominal fee. It also details the necessary precautions against fraudulent applications, with stern penalties for those who falsify information. The Phs520D form serves not just as a procedural document but as a compassionate acknowledgment of a birth and a loss, underlining the state’s commitment to recognize all births, regardless of the outcome. The application process is designed to be respectful and accessible, acknowledging the sensitive nature of the request and the importance of offering a tangible form of recognition to grieving families.
| Question | Answer |
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| Form Name | Form Phs520D |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | BirthResultingS tillbirthApplic ation louisiana phs520f form |
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DEPARTMENT OF HEALTH AND HOSPITALS |
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OFFICE OF PUBLIC HEALTH |
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VITAL RECORDS REGISTRY |
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APPLICATION FOR BIRTH RESULTING IN STILLBIRTH CERTIFICATE |
PHS 520D |
Rev. (9/07) |
FOR MAIL SERVICE: SUBMIT COMPLETED APPLICATION, COPY OF STATE ISSUED PHOTO ID and CHECK OR MONEY ORDER TO: VITAL RECORDS REGISTRY, P.O. BOX 60630, NEW ORLEANS, LA 70160. PLEASE DO NOT SEND CASH.
IF NO RECORD IS FOUND, YOU WILL BE NOTIFIED AND FEES WILL BE RETAINED FOR THE SEARCH PER R.S. 40:40.
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NOT FOR USE TO ORDER CERTIFICATE OF LIVE BIRTH OR CERTIFICATE OF DEATH
Complimentary Birth Resulting in Stillbirth Certificate |
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1 Copy |
NO FEE |
Additional Birth Resulting in Stillbirth Certificate |
# Copies Requested: |
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at $15.00 each = |
$ |
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TOTAL FROM ABOVE: |
$ |
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Mail Orders add .50 state charge per transaction |
$ |
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TOTAL FEES DUE: |
$ |
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* See note below
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NAME OF STILLBORN (IF APPLICABLE) |
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DATE OF STILLBIRTH |
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SEX |
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HOSPITAL OF DELIVERY |
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PARISH OF STILLBIRTH |
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FATHER'S NAME (IF APPLICABLE) |
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MOTHER'S FULL MAIDEN NAME - BEFORE MARRIAGE |
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RELATIONSHIP TO PERSON NAMED ON THE CERTIFICATE: |
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(MUST SUBMIT PHOTO ID) |
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Check one: |
___Mother ___Father |
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PRINT NAME AND MAILING ADDRESS OF APPLICANT: |
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NOTE: PLEASE CHECK THE FOLLOWING: |
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Name |
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Street or |
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____Signed Application |
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Route No. |
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City and |
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____Copy of Federal or State Photo ID |
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State |
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Zip Code |
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____Correct Fees |
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Home |
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Office |
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Phone No. |
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Phone No. |
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I AM AWARE THAT ANY PERSON WHO WILLFULLY AND KNOWINGLY MAKES ANY FALSE AN APPLICATION FOR A CERTIFIED COPY OF A VITAL RECORD IS SUBJECT UPON CONVICTION TO A FINE OF NOT MORE THAN $10,000 OR IMPRISONMENTOF NOT MORE THAN FIVE YEARS, OR BOTH.
Signature of Applicant: _____________________________________________________________
*PLEASE NOTE: Birth records over 100 years old and Death records over 50 years old can be obtained by writing the Secretary of State. Address: Louisiana State Archives, P.O. Box 94125, Baton Rouge, LA