Blank Stillbirth Certificate PDF Template

1. What is a Stillbirth Certificate?

A Stillbirth Certificate is an official document produced by the Department of Public Health that records the stillbirth event. It provides important details such as the name of the stillborn, date and place of stillbirth, gender (if determined), and the parents' names.

2. Who can apply for a Stillbirth Certificate?

Only the parent of the stillborn child can apply for and obtain a Stillbirth Certificate for that particular event. This includes either the mother or the father listed on the fetal death record.

3. What information do I need to provide to apply for the Stillbirth Certificate?

To apply, you must provide the stillborn child's full name as it appears on the fetal death record, the gender (if not undetermined), the date and place of stillbirth, including city and name of hospital or street address if outside a hospital. Additionally, the mother's full name and birth surname, and the father's full name, if applicable, must be included. The applicant's information and a valid government-issued photo identification are also required.

4. How much does it cost to obtain a Stillbirth Certificate?

The fee for a Stillbirth Certificate is $30.00 per copy. This fee is payable to the Treasurer, State of CT. Payment should accompany the application for processing.

5. How do I submit my application and payment?

Applications along with the payment, and a copy of a valid government-issued photo identification, should be mailed to the State Registrar of Vital Records, Department of Public Health, Vital Records-MS#11VRS, 410 Capitol Avenue, Hartford, CT 06134-0308.

6. What forms of payment are accepted?

Money orders are accepted for the payment of the Stillbirth Certificate. They should be made payable to the Treasurer, State of CT. Ensure to include the money order with your application package when mailing.

7. How many copies of the Stillbirth Certificate can I request?

You can request multiple copies of the Stillbirth Certificate. Just specify the number of copies desired in the application form and calculate the total fee accordingly ($30.00 for each copy).

8. Is it necessary for both parents to sign the application form?

Both parents are required to sign the application form only if both are applying. However, if the certificate is being requested by one parent, then only that parent’s signature is necessary. In cases where the mother was unmarried and no Acknowledgment of Paternity (AOP) was filed, the father's detail may be left blank, and thus his signature is not required.

When filling out the Stillbirth Certificate form provided by the State of Connecticut Department of Public Health, it's important to do so accurately and completely to ensure the process goes smoothly. However, several common mistakes can occur:

1. Not printing the stillborn's entire name as it currently appears on the fetal death record can lead to discrepancies and delays. The form requires the name be spelled and presented exactly as recorded.

2. Failure to correctly denote the gender of the stillborn, if it was determined, or marking it improperly can cause confusion. It should be noted that the gender field should be left blank if it is undetermined, as per the instructions.

3. Omitting the father's full name when applicable, especially if the mother was unmarried but an Acknowledgement of Paternity (AOP) was filed, is a common oversight.

4. Incorrectly or incompletely listing the place of stillbirth, including the city or failing to provide the specific street address if the delivery occurred outside of a hospital, can invalidate the application.

5. Forgetting to attach a copy of a valid government-issued photo identification or failing to include the necessary fee with the application can delay or prevent the processing of the stillbirth certificate request.

To avoid these mistakes, thoroughly review all entered information for accuracy and completeness, ensure adherence to instructions regarding specific fields, and double-check that all required documentation and fees are included before submission.

Handling the formalities after the loss of a child is a difficult and emotional task. The Stillbirth Certificate form serves as a critical document for bereaved families, providing official acknowledgment of their child's birth. Apart from the Stillbirth Certificate, several other documents and forms may be necessary during this time. The following list includes descriptions of these additional documents, aiming to provide comprehensive support and information.

• Death Certificate: This official document confirms the death of an individual. In cases of stillbirth, some regions may require or offer a separate death certificate alongside the stillbirth certificate.
• Birth Certificate: In certain circumstances, parents may also receive a birth certificate for a stillbirth event, recognizing the birth despite the unfortunate outcome.
• Acknowledgment of Paternity (AOP) Form: This form is used to establish the legal paternity of a child, which can be important for birth certificates where the father's information is included.
• Funeral Service Contract: When arranging memorial services, parents might enter into contracts with funeral service providers, outlining the details of the service and merchandise provided.
• Burial Permit: This permit is often required to lay the remains to rest in a cemetery or other designated place. It formalizes the legality of the burial location.
• Cemetery Deed: This document provides the legal right of use of a particular plot of land within a cemetery for burial purposes.
• Life Insurance Claim Forms: If the parents had a life insurance policy covering the stillbirth, these forms would be needed to process a claim.
• Medical Records Release Form: Parents may need to obtain detailed medical records related to the pregnancy and stillbirth, requiring a form to authorize release of these confidential documents.
• Social Security Forms: Although stillborn children are not eligible for Social Security benefits, parents might still need to contact the Social Security Administration to update records or inquire about potential impacts on benefits.
• Memorial or Tribute Fund Form: For families wishing to establish a memorial fund in their child's honor, this form starts the process with the chosen charitable organization.

Understanding and completing these documents during a time of grief can be overwhelming. It's important for families to know that there are resources and professionals available to help navigate these processes. Each document serves its purpose in ensuring the child's life is honored and legal matters are carefully addressed. With compassionate support and guidance, families can focus on healing while ensuring their child's memory is preserved and respected.

• Birth Certificate: Similar to a Stillbirth Certificate, a Birth Certificate documents the key facts about an individual's birth, such as the date, place, and parents' names. Both serve as vital records issued by a governmental authority but represent different outcomes in childbirth.

• Death Certificate: A Death Certificate also parallels a Stillbirth Certificate, as it records the end of an individual's life, detailing the date, cause of death, and location. Both certify events vital to legal and personal records, acknowledging the presence of a life, albeit the stages differ.

• Marriage Certificate: Like a Stillbirth Certificate, a Marriage Certificate is a formal document establishing the legal status of a significant life event. Each is used to validate the event's occurrence (marriage or birth/death in the case of stillbirth) for legal, social, and health record purposes.

• Adoption Certificate: This certificate, documenting the legal adoption of a child, shares similarities with a Stillbirth Certificate in that it solidifies a legally and emotionally significant family event, changing or establishing parental rights and child identity.

• Divorce Decree: While documenting a different aspect of family law, a Divorce Decree resembles a Stillbirth Certificate by formalizing changes in personal and legal status, necessitating the involvement of legal documentation to affirm the new status for the parties involved.

• Passport Application: A Passport Application is connected to a Stillbirth Certificate by their requirements for precise and official documentation of personal identity and status (nationality, birthdate, parental information) serving as a basis for further legal identification processing.

• Paternity Declaration: This legal document, which officially recognizes a man as the legal father of a child, is akin to a Stillbirth Certificate in the sense that both involve formal acknowledgment of a parental relationship to a child, affecting legal rights and identity documentation.

When dealing with the sensitive process of filling out a Stillbirth Certificate form, such as the one provided by the State of Connecticut Department of Public Health, it's crucial to handle the task with care and accuracy. Here are essential do's and don'ts to guide you through correctly completing the form:

• Ensure accuracy: Double-check all the information you provide, including spelling of names, dates, and locations. Mistakes can be difficult to correct later.
• Complete all required fields: Fill out every section that applies to your situation. Leave blank those that don’t, such as the father’s full name if not applicable.
• Use black ink: If filling out the form by hand, use black ink for better legibility and to comply with official recording standards.
• Attach required documentation: Be sure to include a valid government-issued photo identification along with the application to verify your identity.
• Review before signing: Carefully review every detail on the form before signing it. Your signature attests to the accuracy of the information provided.
• Ensure appropriate payment: Include the correct amount for the number of copies requested. Remember, as of the last update, each copy costs $30.00.

• Use correction fluid: Avoid using correction fluid or tape. If you make a mistake, it’s better to start over with a new form to maintain the document’s integrity.
• Guess on details: If you’re unsure about specific details, verify them before completing the form. Guessing can lead to inaccuracies that may affect future documentation or processes.
• Use nicknames or initials: Always use the full legal names of everyone mentioned on the form, as nicknames or initials can cause confusion in official records.
• Forget signatures: Forgetting to sign the form or missing the signature of the other parent, when applicable, can invalidate your application.
• Omit contact information: Failing to provide complete contact information, including your telephone number and mailing address, may delay the process.
• Ignore instructions for mailing: Carefully adhere to the specified mailing instructions, including the correct address and any specific documentation requirements, to ensure the application is processed smoothly.

Many people hold misunderstandings about the process and significance of obtaining a Stillbirth Certificate. Here are five common misconceptions clarified:

• It requires extensive legal and medical documentation to apply. In reality, applying for a Stillbirth Certificate is more straightforward than many realize. The parent needs to provide a government-issued photo ID and the application fee. The state has streamlined this process to be accessible and respectful to grieving families.
• Both parents must sign the application for it to be processed. This is not accurate. The form explicitly states that the signature of the mother is necessary, but the father's signature is only required if applicable and available. This considers various circumstances and respects the mother's position in this sensitive process.
• The certificate will list the gender of the stillborn, regardless of the situation. This is incorrect. The form provides an option for 'Undetermined' if the gender of the stillborn is not known or specified. This ensures respect and sensitivity towards the child and the family during a difficult time.
• Only hospitals can issue the Stillbirth Certificate. This misconception overlooks the fact that the application process occurs through the State Department of Public Health, not the hospital. While the place of stillbirth, including the hospital name, is required on the form, the certificate itself is issued by the state’s vital records department.
• There is a lengthy waiting period to receive the Stillbirth Certificate. The waiting period for receiving a Stillbirth Certificate can vary, but the application process has been designed to be as efficient as possible to not add further stress to the grieving families. The form includes details on where to mail the request and the fees involved, indicating a structured process aimed at timely issuance.

Understanding these aspects of applying for a Stillbirth Certificate can help ease some of the pressures and anxieties families may face during this somber time. It’s part of the state’s efforts to provide a measure of comfort and official acknowledgment of the child’s existence to the grieving parents.

Understanding the process and importance of obtaining a Stillbirth Certificate through the State of Connecticut Department of Public Health Vital Records can be a delicate matter for parents experiencing such a loss. Highlighted below are key takeaways that should be noted:

• The Stillbirth Certificate form requires detailed information about the stillborn, including the full name as it appears on the fetal death record, the gender (if determined), the date and place of stillbirth, and the name of the hospital or address where the stillbirth occurred.
• Applicants must be the parent of the stillborn to request and obtain a copy of the Stillbirth Certificate. This underscores the personal and sensitive nature of the document, ensuring privacy and restricted access to such a vital record.
• It is mandatory to provide a valid government-issued photo identification along with the application to authenticate the identity of the requester. This step is crucial to prevent fraud and unauthorized access to personal records.
• The application process involves a fee of $30.00 per copy. This fee must be paid by making a money order payable to the Treasurer, State of Connecticut. The fee structure is in place to cover the cost of processing and issuing the certificate.
• Mailing instructions are clear and specific, directing applicants to send their request, including the photo identification and required fee, to the State Registrar of Vital Records at a designated address. This structured process ensures that the application is directed to the proper channel for processing and issuance.

Acquiring a Stillbirth Certificate acknowledges a significant event and provides parents with a document that recognizes their child's birth, despite the unfortunate outcome. It serves not only as a formal record but also as a step towards healing for the grieving family.