Form VS 12 Application for Certified Copy of Fetal Death Record - California

Form VS12 or the "Application For Certified Copy Of Fetal Death Record" is a form issued by the California Department of Public Health.

The form was last revised in January 1, 2018 and is available for digital filing. Download an up-to-date Form VS12 in PDF-format down below or look it up on the California Department of Public Health Forms website.

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INSTRUCTIONS
Mail the following items to CDPH-VR:
For STILL BIRTHS ONLY:
Vital
Records
maintains
a
1) Completed “Application for Certified
permanent, public record of every
Copy of Still Birth Record” (VS 13-E).
birth and death that has occurred in
California since July 1905, and has
2) $24 fee per copy requested.
more than 50 million records on file.
For FETAL DEATHS ONLY:
1) Completed “Application for Certified
Copy of Fetal Death Record” (VS 12).
2) $18 fee per copy requested.
Be sure to complete all items required on
the application, and provide as much
information as possible to help locate the
record, otherwise your request may be
returned to you for correction.
How to Obtain
Fees
are
payable
to
“CDPH
Vital
Records” via check or money order.
Certified Copies of
International money orders for out-of-
country requests must be payable in U.S.
Still Birth and
dollars. Fees are also non-refundable per
Fetal Death Records
state law.
If CDPH-VR cannot locate the record
January 1, 2018
based on the information you provide,
California
Health
and
Safety
Code
authorizes CDPH-VR to maintain the fee
for the search itself, and CDPH-VR will
issue a Certificate of No Public Record
(CNPR).
California Department of Public Health
If you require documentation that a
Vital Records – MS 5103
record does not exist, check the CNPR
P.O. Box 997410
box on the application.
Sacramento, CA 95899-7410
(916) 445-2684
Fees previously paid to local registrars
www.cdph.ca.gov
and county recorder’s offices cannot be
CA Relay: 711/1-800-735-2929
transferred to CDPH-VR.
INSTRUCTIONS
Mail the following items to CDPH-VR:
For STILL BIRTHS ONLY:
Vital
Records
maintains
a
1) Completed “Application for Certified
permanent, public record of every
Copy of Still Birth Record” (VS 13-E).
birth and death that has occurred in
California since July 1905, and has
2) $24 fee per copy requested.
more than 50 million records on file.
For FETAL DEATHS ONLY:
1) Completed “Application for Certified
Copy of Fetal Death Record” (VS 12).
2) $18 fee per copy requested.
Be sure to complete all items required on
the application, and provide as much
information as possible to help locate the
record, otherwise your request may be
returned to you for correction.
How to Obtain
Fees
are
payable
to
“CDPH
Vital
Records” via check or money order.
Certified Copies of
International money orders for out-of-
country requests must be payable in U.S.
Still Birth and
dollars. Fees are also non-refundable per
Fetal Death Records
state law.
If CDPH-VR cannot locate the record
January 1, 2018
based on the information you provide,
California
Health
and
Safety
Code
authorizes CDPH-VR to maintain the fee
for the search itself, and CDPH-VR will
issue a Certificate of No Public Record
(CNPR).
California Department of Public Health
If you require documentation that a
Vital Records – MS 5103
record does not exist, check the CNPR
P.O. Box 997410
box on the application.
Sacramento, CA 95899-7410
(916) 445-2684
Fees previously paid to local registrars
www.cdph.ca.gov
and county recorder’s offices cannot be
CA Relay: 711/1-800-735-2929
transferred to CDPH-VR.
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ATTENTION:
PLEASE READ THE FOLLOWING INFORMATION
BEFORE COMPLETING APPLICATION
APPLICANT NOTIFICATION
Once
your
request
has
been
received and evaluated:
CONTACT INFORMATION
GENERAL INFORMATION
If your request is not accepted
All
applications
and
written
Information contained in vital
(e.g., due to insufficient fees,
inquiries should be mailed to:
records is released only via
insufficient
information,
etc.),
requests for certified copies.
CDPH-VR will return your re-
California Department of Public
quest to you with a letter explain-
Health
Certified copies of still births are
ing what needs to be corrected;
Vital Records – MS 5103
available for release to the
or,
P.O. Box 997410
mother/parent or father/parent
Sacramento, CA 95899-7410
If your request is accepted,
only.
If you still have any questions,
CDPH-VR will process the appli-
Certified copies of fetal death
cation and mail out a copy of the
please contact the CDPH-VR
certificates are available for
certificate(s) you requested.
Customer
Service
Unit
at
release to anyone who can
(916) 445-2684, Monday through
Please allow a few weeks to receive
provide sufficient information to
Friday, between 8AM – 4PM.
these documents.
identify a specific record.
PROCESSING TIMES
To check current processing times
for certified copies of still birth
certificates and fetal death records,
visit the following website:
Vital Records Processing Times
P
(https://www.cdph.ca.gov/Programs/CHSI/
ages/Vital-Records-Processing-
Times.aspx)
State of California – Health and Human Services Agency
California Department of Public Health
APPLICATION FOR CERTIFIED COPY OF FETAL DEATH RECORD
INFORMATION:
Fetal death records have been maintained in the California Department of Public Health Vital Records since July 1, 1905.
INSTRUCTIONS:
1.
Complete a separate application for each fetal death record requested.
2.
Complete the Applicant Information section and provide your signature where indicated. In the Fetal Death Information section,
provide all the information you have available to identify the fetal death record. If the information you furnish is incomplete or
inaccurate, we may not be able to locate the record. If you require documentation that a fetal death record does not exist, check the
box for CNPR (Certificate of No Public Record) Request.
3.
Submit $18 for each copy requested. If no fetal death record is found, the fee will be retained for searching the record (as required
by law) and a “Certificate of No Public Record” will be issued to the applicant. Indicate the number of copies you want and include
the correct fee(s) in the form of a personal check or postal or bank money order (International Money Order for out-of-country
requests) made payable to CDPH Vital Records. PLEASE SUBMIT CHECK OR MONEY ORDER DO NOT SEND CASH (CDPH cannot be
̶
held responsible for fees paid in cash that are lost, misdirected, or undelivered).
4.
Mail completed applications with the fee(s) to:
California Department of Public Health
Vital Records ̶ MS 5103
P.O. Box 997410
Sacramento, CA 95899-7410
(916) 445-2684
$18 per copy
PLEASE SUBMIT CHECK OR MONEY ORDER ̶ DO NOT SEND CASH
Fee:
(payable to CDPH Vital Records).
(CDPH cannot be held responsible for fees paid in cash that are lost, misdirected, or undelivered).
APPLICANT INFORMATION (PLEASE PRINT OR TYPE)
Today’s Date:
Agency Name (if applicable)
Agency Case Number
Inmate ID Number
Print Name of Applicant
Signature of Applicant
Purpose of
Check this
Request
box for CNPR
Request
Mailing Address – Number, Street
Amount Enclosed – DO NOT SEND CASH
Number of Copies
$
Check
$
Money Order
City
Name of Person Receiving Copies, if Different from Applicant
State/Province
ZIP Code
Mailing Address for Copies, if Different from Applicant
Country
Email Address
City
State
ZIP Code
Daytime Telephone Number
(
)
FETAL DEATH INFORMATION (PLEASE PRINT OR TYPE)
Complete information below as shown on the fetal death record, to the best of your knowledge.
FETAL DEATH FIRST Name
MIDDLE Name
LAST Name
City of Fetal Death (must be in California)
County of Fetal Death
Date of Fetal Death – MM/DD/CCYY (If unknown, enter approximate date of fetal death)
Father/Parent FIRST Name
MIDDLE Name
LAST Name (Before Marriage/Domestic Partnership)
Mother/Parent FIRST Name
MIDDLE Name
LAST Name (Before Marriage/Domestic Partnership)
FETAL DEATH
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VS 12 (01/18)

Download Form VS 12 Application for Certified Copy of Fetal Death Record - California

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