Fillable Report of Fetal Death and/or Certicate of Birth (North Carolina)

Fill Online, Printable, Fillable, Blank Report of Fetal Death and/or Certicate of Birth (North Carolina) Form

Use Fill to complete blank online NORTH CAROLINA pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Report of Fetal Death and/or Certicate of Birth (North Carolina)

On average this form takes 14 minutes to complete

The Report of Fetal Death and/or Certicate of Birth (North Carolina) form is 1 page long and contains:

  • 0 signatures
  • 15 check-boxes
  • 47 other fields

Country of origin: US
File type: PDF

BROWSE NORTH CAROLINA FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
North Carolina Department of Health and Human Services
Division of Public Health • N.C. Vital Records
https://vitalrecords.nc.gov
Telephone: 919-733-3000
Mail: NCOVR
ATTN: Fetal Death
1903 Mail Service Center
Raleigh, NC 27699-1900
Location: 225 North McDowell St.
Raleigh, NC 27603-1382
Application for a Copy of a North Carolina
Report of Fetal Death and/or Certicate of Birth Resulting in Stillbirth
The Vital Records ofce will issue copies of Fetal Death Reports on le for events occurring July 1, 2001–forward along with a Stillbirth Certicate if
requested.
According to G.S. 130A-114, if the fetal death occurred in this State prior to July 1, 2001, the State Registrar may not issue a Certicate of
Birth Resulting in Stillbirth unless the customer’s application for the certicate is accompanied by a certied copy of the Fetal Death Report.
A Stillbirth Certicate costs $24 for events occurring prior to 2001. A Report of Fetal Death search also costs $24 and includes one copy if a certicate is
located. The search covers a three-year period. This search fee is non-refundable. There is a $15 fee for each additional certificate copy requested from the
same search. If you want same-day walk-in service, an additional $15 expedited processing fee is required. Make your certified check or money order payable to
“N.C. Vital Records.” Please do not send cash in the mail. Personal checks are not accepted. If you have questions, our telephone number is 919-733-3000.
Identication of the person requesting a certicate is required. See page 2 for a list of acceptable IDs.
Full Name of Fetus
(If named)
___________________________________________________________________________________
First Name Middle Name Last Name
Date of Delivery
____ | ____ | ________
Month Day Year
Sex Male Female
ORDER CERTIFICATES HERE
Fetal Death Report search and rst copy x $24 $ _____
____ Number of additional copies from the same search x $15 $ _____
Fetal Death Report search/rst copy and Stillbirth Certicate x $24 $ _____
____ Number of additional copies from the same search x $15 $ _____
Stillbirth Certicate (prior to 2001) rst copy x $24 $ _____
____ Number of additional copies from the same search x $15 $ _____
$ _____
$ _____
Add $15 for processing changes to Fetal Death Report
Certified check or money order only if mailing in. Cash and debit/credit cards permitted in person.
Check one:
Amendment Paternity—no fee required
Amount Due $ _________
Indicate Type of Reports/Certicates Needed and Quantity
Fetal Death Report
Certied
(Suitable for legal purposes) ______
Uncertied
(Not suitable for legal purposes) ______
Stillbirth Certicate
Certied
(Suitable for legal purposes) ______
Uncertied
(Not suitable for legal purposes) ______
Total Number of Reports/Certicates Needed
(Total must match quantity ordered at left)
Fetal Death Report Stillbirth Certicate
Your relationship to the person whose Fetal Death Report is requested: (Check One) Released only to parents in accordance with G.S. 130A-114
Brother/Sister
Parent/Stepparent
Grandparent
Authorized agent, attorney or legal representative
of the person listed (Proof REQUIRED)
Other (may not be entitled to a certied copy)
Specify __________________________________
Parent
I hereby certify that all the above information is true to the best of my knowledge. Note: It is a felony violation of North Carolina Law (G.S.
130A-26A) to make a false statement on this application or to unlawfully obtain a copy or a certied copy of a vital record.
________________________________________________________ ________________________________
Signature of Person Requesting the Certicate Print Name of Person Requesting the Certicate
________________________________________________________ ________________________________
Street Address or P.O. Box (P.O. Box cannot be used for expedited shipping.) Date Signed
________________________________________________________ ________________________________
City, State and Zip Code (Area Code) Telephone Number (During business hours)
Place of Delivery
Full Name of Father/Parent
Full Name of Mother/Parent
Ofce Use Only: SFN ____________________________ DCN _________________________ Cartridge/Frame __________________________
Amount received: $________________ Identication presented__________________________________________________________________
Request number _____________________________________ Request date ________________________________________________________
DHHS-VR-FD (Revised 01/2022)
NC Office of Vital Records
Please Print
__________________________________________________________________________________
City County
____________________________________________________________________
First Name Middle Name Last Name Last Name prior to rst marriage, if applies
____________________________________________________________________
First Name Middle Name Last Name Last Name prior to rst marriage, if applies
Order Certi icate
A certificate search costs $24 and includes one copy if the certificate is located. Each search fee covers a
three-year range. Requests are processed in the order received. The search fee is required to process a request
and is non-refundable even if a record cannot be located.
For current processing times for requests, see our website at https://vitalrecords.nc.gov/processing-dates.htm.
Identication Requirement
Due to identity theft and other fraudulent use of vital records, ID of the person requesting a certicate is
REQUIRED. Requests that do not include ID will be returned. You MUST include a legible photocopy of
one of the photo IDs listed below with your request:
• Current state-issued driver’s license (address must match requestor’s address on application)
• Current state-issued non-driver photo ID card (address must match requestor’s address on application)
• Current Passport or Visa (must include photo)
• Current U.S. military ID
• Current Department of Corrections photo ID card dated within the last year
• Current state or U.S. government agency photo ID card (for persons requesting certicates as part of that
agency’s business)
• Current student ID card with copy of transcript
If you do not have one of the IDs listed above, you must provide legible photocopies of TWO of the following
(must be two DIFFERENT forms of ID):
• Temporary driver’s license
• Current utility bill with current address
• Car registration or title with current address
• Bank statement with current address
• Pay stub with current address
• Income tax return/W-2 form showing current address
• Letter from government agency dated within the last six months and showing current address
• State-issued concealed weapon permit showing current address
If you are unable to meet our ID requirements, a family member or other person
who is entitled to obtain the certicate, and who can meet the ID requirements, may request it.
A list of persons entitled to obtain certificates is located on our website at
https://vitalrecords.nc.gov/faqs.htm.
DHHS-VR-FD (Revised 01/2022)
NC Office of Vital Records
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Report of Fetal Death andor Certicate of Birth (North Carolina)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 8 May 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document