“Certificate of Birth Resulting in Stillbirth”

 

From the State of Minnesota

 

As of August 2005

 

 

1.                  The “Certificate of Birth Resulting in Stillbirth” is only available through the state offices. You Can Not obtain this certificate at your local county offices.

 

2.                  The “Certificate of Birth Resulting in Stillbirth” is for infants who have been stillborn at the gestational age of 20 weeks or greater.

 

3.                  Only the parents listed on the record of birth may request the certificate. This would be the mother and father (if he is listed).

 

4.                  To request the paperwork needed to file for the “Certificate of Birth Resulting in Stillbirth” please complete the following Minnesota Department of Health (MDH) paper work (see attached) OR visit the Minnesota Department of Health (MDH) website: www.health.state.mn.us and download the form listed below:

 

A.     Minnesota Application to File a Record and Request  Certificate For A Birth Resulting In Stillbirth

 

Forms are also available by contacting:

 

Minnesota Department of Health

            Attention: Office of the State Registrar

            P.O. Box 64882

            St. Paul, MN  55164-0882

(651) 201-5970

E-mail:  OSR7@health.state.mn.us

 

OR

 

Infants Remembered In Silence, Inc. (IRIS)

101 Third Street NW

Faribault, MN 55021-5143

(507) 334-4748

E-mail:  iris@LL.net

Website: www.irisremembers.com

           

 

If your child was stillborn within the last 12 months at a MN Hospital:

 

                       

A.                 Complete the Certificate For a Birth Resulting in Stillbirth paperwork  (see attached form)

 

B.                 Your signature must be notarized. This can be done in the IRIS office or by any Notary Public.

                       

            C.              If you would like to order a certificate please include the following fee:

 

                        First Certificate for each stillborn child - $16

                        Additional certificates - $9

 

            D.              Send the completed and notarized form along with payment to the address below.             

 

E.              If you wish you can also obtain a copy of your child’s Fetal Death Report at your local Registers office. There is a $9 Fee.

 

 

 

 

  If your child was stillborn in MN 13 months ago or longer,

Or if your child was stillborn in a location other then a Hospital:

 

A.                 Complete the Certificate For a Birth Resulting in Stillbirth paperwork  (see attached form)

 

            B.            Your signature must be notarized. This can be done in the IRIS office or by any Notary Public.

                       

C.              Obtain a copy of the fetal death report from your local registrars office.  $9 Fee

 

And / OR

 

Obtain an authenticated medical record from your Doctor / Midwife

                                               

                                    This record / letter must be on clinic / business letterhead and include:

                                    Delivery location in MN

                                    Date of delivery

                                    Child’s gestational age (must be at least 20 gestational weeks or more)

                                                                        Doctor’s / Midwife signature

 

D.                If you would like to order a certificate please include the following fee:

 

                         Delayed Filing Fee for each stillborn child - $40

                        First Certificate for each stillborn child - $16

                        Additional certificates - $9 each

 

 

Mail completed application, documentation and fees to:

 

 

 

                        Minnesota Department of Health

                        Attention: Office of the State Registrar

                        P.O. Box 64882

                        St. Paul, MN  55164-0882

 

 

        August 2005, revised May 2006