Free Stillbirth Certificate Form in PDF

Instructions on Writing Stillbirth Certificate

Filling out a Stillbirth Certificate form is a necessary step for families who have experienced a stillbirth and wish to have a formal record of the event. This document is issued by the State of Connecticut Department of Public Health. It is essential to complete this form accurately and submit the required documentation and payment to obtain a certified copy of a Stillbirth Certificate. Below are the detailed instructions to assist you in filling out the form properly.

1. Print the entire name of the stillborn in the space provided, exactly as it appears on the fetal death record.
2. Indicate the gender of the stillborn by checking the appropriate box for Male, Female, or Undetermined. Note that for Undetermined, the gender will not be listed.
3. Enter the date of stillbirth in the format of month, day, and year.
4. Fill in the place of stillbirth, including the city. If the birth occurred in a hospital, write the name of the hospital. If the birth occurred outside of a hospital, provide the street address of the delivery location.
5. Write the mother’s full name at the time of stillbirth, including first, middle, and last names.
6. Enter the mother’s birth surname (her last name at birth).
7. Provide the father’s full name as of the date of stillbirth. If the mother was unmarried and no Acknowledgement of Paternity (AOP) was filed, this item may be left blank.
8. Under Applicant Information, print or type the name of the parent requesting the certificate.
9. Include a telephone number with the area code for the requester.
10. Provide the requester’s complete mailing address, including the city, state, zip code, and apartment number if applicable.
11. Indicate the number of copies requested in the space provided.
12. Attach a copy of a valid government-issued photo identification of the parent making the request.
13. Prepare the payment of $30.00 per copy requested. Make the money order payable to the Treasurer, State of Connecticut.
14. The mother's signature and the date signed are required. If applicable, the father's signature and the date signed must also be provided.
15. Mail the completed application form, a copy of the photo ID, and the payment to: State Registrar of Vital Records, Department of Public Health, 410 Capitol Avenue, Hartford, CT 06134-0308.

Following these detailed instructions, you can accurately complete the Stillbirth Certificate form and submit it along with the required documents and fees. This careful completion helps ensure the timely processing of your request, ultimately providing a certified record that officially acknowledges the stillbirth. This document is a vital piece in legal and personal records, facilitating closure and memorialization according to state regulations.

What is a Stillbirth Certificate?

A Stillbirth Certificate is an official document issued by the State of Connecticut Department of Public Health that records the occurrence of a stillbirth. It includes vital information such as the name of the stillborn child, date and place of stillbirth, gender, and parents' names.

Who can apply for a Stillbirth Certificate?

Only the parent of the stillborn child may file for and obtain a copy of a Stillbirth Certificate. It is required that the parent submitting the application must provide a valid government-issued photo identification alongside the application.

What information is needed to fill out the application form?

The application form requires detailed information including the full name of the stillborn child as it appears on the fetal death record, gender, date and place of stillbirth, the name of the hospital or the street address if the birth occurred outside a hospital, full names of the mother and father at the time of stillbirth, and the mother's birth surname.

Is there a fee to apply for a Stillbirth Certificate, and how can payment be made?

Yes, there is a fee of $30.00 per copy of the Stillbirth Certificate. Payment can be made via money order, payable to the Treasurer, State of Vital Records-MS#11VRS. It is important to include the payment with your mail request.

Where should the application for a Stillbirth Certificate be sent?

Completed applications, along with the required payment and a copy of the requestor's photo identification, should be mailed to the State Registrar of Vital Records, Department of Public Health, 410 Capitol Avenue, Hartford, CT 06134-0308.

How many copies of the Stillbirth Certificate can be requested?

There is no specified limit on the number of copies that can be requested. However, remember there is a fee of $30.00 for each copy requested. Specify the number of copies needed on the application form.

What if the father's information is unknown or not applicable?

If the mother was unmarried at the time of stillbirth and no Acknowledgment of Paternity (AOP) was filed, the section for the father's full name on the application may be left blank. It's important to provide as much information as is available and applicable to your situation.

One common mistake people make when filling out the Stillbirth Certificate form is not printing the name of the stillborn exactly as it appears on the fetal death record. Accuracy here is crucial to ensure the request is processed without delays. Names should be double-checked for any spelling discrepancies to avoid potential issues with the record's retrieval and the certificate's validity.

Another error often seen involves the section requesting the gender of the stillborn. In cases where the gender is undetermined, some applicants mistakenly choose "Male" or "Female" instead of selecting "Undet." It's vital to note that for undetermined genders, the document specifically advises not listing gender, thereby requiring careful attention to this detail.

The date of stillbirth is frequently entered incorrectly. It’s imperative to provide the exact month, day, and year as they play a significant role in identifying the specific record. Any deviation from the factual date can lead to an unsuccessful search or the issuance of an incorrect certificate.

Incorrectly identifying the place of stillbirth is a mistake that can cause significant delay. Whether the stillbirth occurred in a hospital or at another location, the form necessitates a precise location. Providing a vague or incorrect address or hospital name complicates the record-keeping process and retrieval efforts.

Failing to list the mother’s full name as of the date of stillbirth, including the correct birth surname, is an error that can hinder the documentation process. It's essential to ensure that the mother's name is accurately reflected, as discrepancies can lead to questions about the certificate's authenticity and may necessitate further verification.

Omitting the father’s full name when applicable, especially if the mother was married at the time of stillbirth or an Acknowledgment of Paternity was filed, is another oversight. While the form allows this field to be left blank under certain conditions, neglecting to fill it out when applicable can result in incomplete records.

Finally, the requirement for the parent filing the request to include a valid government-issued photo identification and the payment of $30.00 is occasionally disregarded. This oversight can cause the entire request to be delayed or rejected. Ensuring that all required documentation and fees accompany the application is critical for its timely and successful processing.

Dealing with the loss of a child is a profoundly painful experience, and navigating through the necessary paperwork can add to the distress. The Stillbirth Certificate is a crucial document for parents dealing with such a loss. It serves not only as a formal acknowledgment of the stillbirth but also as a necessary document for various legal and personal reasons. Alongside the Stillbirth Certificate, there are several other forms and documents that parents may need to complete or obtain for various purposes. Understanding these documents can help parents navigate through the necessary steps during this difficult time more smoothly.

1. Death Certificate: Required for legal recognition of the stillbirth; it may be needed for burial or cremation arrangements and for closing or transferring the infant's estate.
2. Birth Certificate: In some cases, parents may also receive a birth certificate, depending on the gestation period at the time of loss or state laws.
3. Application for Social Security Benefits: While not applicable in the case of a stillborn child, understanding social security benefits for other children in the household might be necessary.
4. Permission for Cremation or Burial: This document gives official permission for burial or cremation of the stillborn and is often required by cemeteries and crematoriums.
5. Parental Leave Forms: Depending on the employer's policies and state laws, parents may be eligible for bereavement or parental leave. Documentation from a healthcare provider may be required.
6. Beneficiary Forms for Life Insurance: If the parents had a life insurance policy for the unborn child, they might need to submit a death certificate and the stillbirth certificate to process claims.
7. Memorial Service Arrangements: Though not a legal document, organizing a memorial service might require reservations and arrangements with service providers, which may require a copy of the stillbirth certificate.
8. Counseling Service Referral Forms: Healthcare providers may offer referrals for bereavement counseling services, which might require documentation for insurance or for the service provider’s records.
9. Personal Keepsake Documents: Hospitals or health care providers sometimes offer to create keepsake documents, such as footprints or a lock of hair, as a personal memento for the grieving parents.

Completing and obtaining these documents can be part of the healing process, allowing parents to honor their child’s memory legally and personally. It's important to approach these tasks with sensitivity and understanding, recognizing the deep emotional impact they carry. Organizations and healthcare providers are generally ready to assist grieving parents through these processes, providing not only necessary forms and documents but also emotional support during such a devastating time.

The Birth Certificate is one of the documents bearing a strong resemblance to the Stillbirth Certificate in terms of purpose and content. Both serve as vital records documenting significant life events and are issued by a governmental authority, typically the Department of Public Health. Each of these certificates contains crucial information including full names, gender, and places of occurrence (city or hospital). Furthermore, they require the parent or legal guardian's details and signatures, evidencing a direct relation between the recorded event and the person requesting the document. Birth certificates, like stillbirth certificates, often play a key role in legal and personal identification processes.

The Death Certificate closely parallels the Stillbirth Certificate in its registration of an end-of-life event. While a stillbirth certificate pertains to a birth with no signs of life at or after 20 weeks of gestation, a death certificate is for individuals who have lived outside the womb. Both documents capture similar details, such as date and place of the event and parental or informant information. Moreover, issuing authorities require these certificates for registering the event in the public record, serving as an official acknowledgment of the occurrence.

The Application for a Marriage Licence is another document with similarities to the Stillbirth Certificate, although it pertains to the beginning of a legally recognized relationship rather than a life event. Like the stillbirth certificate form, applications for marriage licenses require detailed personal information about the parties involved (in this case, the individuals getting married) and their consent signatures. These documents must be filed with a government office, often the county clerk or records office, to legally validate the event or status they represent.

Passport Applications share certain features with the Stillbirth Certificate, especially regarding the necessity for detailed personal information and official processing through a governmental body. Both forms necessitate full names, dates, and places related to the event or individual (birthplace for passports, place of stillbirth for stillbirth certificates). They also require the applicant's signature and a fee payable to the issuing authority. While serving different functions—one for international travel identification and the other for registering a stillbirth—both are formal documents necessitating accuracy and formality in their procurement.

The Social Security Number (SSN) Application shows a resemblance in its requirement for detailed applicant information, much like the Stillbirth Certificate. Both ask for names, including maternal maiden names, and other identifiers, although for different purposes. The SSN application is for obtaining a unique identifier for U.S. citizens and residents that is used for a multitude of reasons, from employment to tax reporting. While one document serves an individual across their lifetime, the other records a specific, saddening event with lasting implications for the family.

Driver's License Applications, while primarily for another purpose, contain elements that mirror the process and requirements seen in the Stillbirth Certificate application. Applicants must provide personal information, including name and birth details, and similarly, a fee is typically required. Both documents necessitate government approval for issuance and serve as formal recognitions of a status or event—driving eligibility in one case, and the occurrence of a stillbirth in the other. Additionally, photographic identification is necessary to validate the applicant's identity in both instances.

Lastly, the Petition for Adoption is akin to the Stillbirth Certificate in terms of its legal significance and the solemnity of the circumstances it addresses. Both forms involve detailed personal information, legal proceedings, and the transformation of familial relationships. They require official submission to and processing by a governmental or judicial entity, acknowledging a significant life event. While adoption petitions facilitate the creation of legal parental ties, stillbirth certificates solemnly record the loss of what was anticipated to be such a relationship.

When filling out a Stillbirth Certificate form, especially one as crucial as the State of Connecticut Department of Public Health Vital Records' form, you'll want to navigate the process as smoothly as possible. Here are some key do's and don'ts to guide you:

• Do print the entire name of the stillborn as it appears on the fetal death record. Accuracy here is vital for official records.
• Don't attempt to list a gender if "Undetermined" is a more accurate representation, as specified that "Gender will not be listed for Undetermined."
• Do accurately fill out the date and place of stillbirth, ensuring that all details match existing records and documents.
• Don't list a hospital name if the delivery happened outside one. Instead, the precise address of the delivery location is required.
• Do provide the mother's full name as of the date of the stillbirth, including her birth surname, to avoid any discrepancies in the record.
• Don't fill in the father's full name if the mother was unmarried and no Acknowledgment of Paternity (AOP) was filed—this field can be left blank.
• Do ensure that only a parent of the stillborn is filing and obtaining a copy of the stillbirth certificate, as required by the form. This means that the parent must also submit valid government-issued photo identification and the appropriate fee.
• Don't forget to sign the application form and include the date signed. Both parents, if applicable, should sign, indicating their acknowledgment and request for the stillbirth certificate.

Following these guidelines will help ensure the process is handled with care and respect, while also securing an accurate and official record of your loss. Should you have any questions, officials at the Department of Public Health are ready to assist you.

When it comes to navigating the emotional and sometimes bureaucratic waters of obtaining a stillbirth certificate, there are quite a few misunderstandings. Let's clarify some common misconceptions about the Stillbirth Certificate form from the State of Connecticut Department of Public Health.

• Only the mother of the stillborn can file and obtain a copy of the stillbirth certificate. This is not entirely true. The form clearly states that only the parent of the stillborn may file and obtain a copy of the stillbirth certificate. This includes both the mother and the father, provided the father's information is included at the time of filing or an Acknowledgment of Paternity (AOP) was filed.

• The gender of the stillborn will always be listed on the certificate. This is incorrect. The form specifies that the gender will not be listed for undetermined cases. The parents have the option to choose "Undet." for gender if it was not determined or if they prefer not to specify.

• You can obtain a stillbirth certificate at any time after the event. While this may generally be true, the efficiency and ease of obtaining the certificate can depend on the completeness of records and adherence to the submission guidelines stated on the form. Proper identification and the stated fee must accompany the application for it to be processed.

• Anyone can request a stillbirth certificate as long as they pay the fee. This is a significant misunderstanding. As per the application form, only the parent of the stillborn is authorized to file for and receive a copy of the stillbirth certificate. This is to ensure privacy and respect for the family's sensitive situation.

• There is no cost associated with obtaining a stillbirth certificate. On the contrary, there is a fee required when submitting an application for a stillbirth certificate, as clearly stated on the form. The current fee is $30.00 per copy, which must be paid by making a money order payable to the Treasurer, State of CT.

• The process is complicated and requires an attorney. While navigating the process of obtaining a stillbirth certificate during such a difficult time can feel overwhelming, the form and its instructions aim to make the process as straightforward as possible. There is no indication that legal assistance is necessary to complete and submit the application, provided the instructions are followed correctly.

Understanding these key points can make a significant difference in the experiences of those who must navigate this process during a period of mourning. It's always beneficial to read the application instructions carefully and reach out to the State Registrar of Vital Records with any specific questions or clarifications.

Filling out and using the Stillbirth Certificate form, issued by the State of Connecticut Department of Public Health, involves several key steps and important considerations. Here are seven essential takeaways:

• Specificity Required: When filling out the form, it's crucial to print the entire name of the stillborn as it appears on the fetal death record, ensuring accuracy and consistency in the child's official documents.
• Gender Specification: The form asks for the gender of the stillborn, with options including male, female, and undetermined. It’s important to note that the gender will not be listed if it is undetermined, respecting the sensitivity of the information.
• Detailing Place of Stillbirth: Applicants must specify the place of stillbirth, including the city and whether it occurred in a hospital. If outside a hospital, the exact street address is required, highlighting the importance of precise location information.
• Parental Details Are Mandatory: The form requires full names of the mother and father at the time of stillbirth. However, if the mother was unmarried and no Acknowledgment of Paternity (AOP) was filed, the father’s name can be left blank, which emphasizes the need for clarity regarding parental information.
• Exclusive Access for Parents: Only a parent of the stillborn can file and obtain a copy of the Stillbirth Certificate, underscoring the privacy and exclusivity of this sensitive document.
• Identification and Payment: A valid government-issued photo identification and a payment of $30.00 are required to process the request for a stillbirth certificate, stressing the importance of formal identification and the financial aspect of acquiring the document.
• Submission Details: The completed application, along with the identification and fee, must be mailed to the State Registrar of Vital Records at the Department of Public Health in Hartford, Connecticut. This detail is crucial for ensuring the request reaches the appropriate destination for processing.

In sum, obtaining a Stillbirth Certificate in Connecticut is a process that requires careful attention to detail, respecting the formal requirements and procedural steps. It encapsulates a balance between providing necessary information and adhering to privacy standards, emphasizing the significance of this document to the parents involved.