Stillbirth Certificate Form PDF Details

The Stillbirth Certificate form, issued by the State of Connecticut Department of Public Health Vital Records, is an essential document for parents coping with the loss of a stillborn child. This document serves not only as a formal recognition of the stillbirth but also enables parents to obtain a tangible record of their child's existence. The form requires detailed information such as the stillborn's full name, gender, date and place of stillbirth, and the parents’ names, highlighting the importance of accurately recording this sensitive and significant life event. For mothers, their birth surname is requested, while the father’s full name may be omitted if the mother was unmarried and no acknowledgment of paternity (AOP) was filed, respecting a wide range of family circumstances. The process is designed to be accessible exclusively to the parents of the stillborn, emphasizing the personal and private nature of the loss. A government-issued photo identification and a fee payment are necessary to file and obtain a copy of the stillbirth certificate, underscoring the legal and procedural safeguards around this deeply emotional document. The form also specifies the method of application, including the address to mail the request and the associated fee, making it clear how to complete this important step during a difficult period.

QuestionAnswer
Form NameStillbirth Certificate Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmiscarriage birth certificate, blank stillbirth certificate, baby death certificate template, certificate of life miscarriage

Form Preview Example

State of Connecticut

Department of Public Health

Vital Records 6/05;10/1/09

VS-7

APPLICATION FOR

STILLBIRTH CERTIFICATE

 

 

 

 

 

NAME OF STILLBORN. Print the entire name as it currently appears on the fetal death record.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GENDER

 

 

DATE OF STILLBIRTH

PLACE OF STILBIRTH - CITY

 

 

Stillbirth Information

 

 

 

Male

Female

Undet.

(Month/Day/Year)

 

 

 

 

 

 

 

(Gender will not be listed for Undetermined)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF HOSPITAL (If delivery occurred outside of a hospital, list the street address where the delivery occurred.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MOTHER’S FULL NAME (As of the Date of Stillbirth) (First/Middle/Last)

MOTHER’S BIRTH SURNAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FATHER’S FULL NAME (As of the Date of Stillbirth) (This item may be left blank if mother was unmarried and no AOP was

 

 

 

 

 

 

filed.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ONLY THE PARENT OF THE STILLBORN MAY FILE AND OBTAIN A COPY OF A STILLBIRTH

 

 

 

 

 

 

CERTIFICATE FOR THAT EVENT. THE PARENT MUST SUBMIT A VALID GOVERNMENT ISSUED

 

 

 

 

 

 

PHOTO IDENTIFICATION AND PAYMENT OF $30.00.

 

 

 

 

Applicant Information

 

 

 

Requestor Name (Print or Type). Requestor must attach a

Telephone Number (Include Area Code)

 

 

 

 

 

copy of picture identification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Requestor Complete Mailing Address (include

City/State/Zip Code

 

 

 

 

 

 

apartment number if applicable)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of Copies requested.________

 

Mail Request and identification to:

 

 

Copies &

Fees

 

 

Fee: $30.00 per copy

 

State Registrar of Vital Records

 

 

 

 

 

Department of Public Health

 

 

 

 

Make Money Orders Payable to: Treasurer, State of

 

 

 

 

 

 

 

 

 

 

 

 

Vital Records-MS#11VRS

 

 

 

 

 

 

CT

 

 

 

 

 

 

 

 

 

 

 

 

410 Capitol Avenue

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hartford, CT 06134-0308

 

 

 

 

 

 

 

 

 

 

 

 

Applicant Signature

 

 

 

SIGNATURE OF MOTHER

 

 

DATE SIGNED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF FATHER

 

 

 

DATE SIGNED

 

 

 

 

 

 

 

 

 

 

 

 

 

S:\efrugale\stillbirthcertificate.doc

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