Form REG-68 "Request to Place on File a Certificate of Birth Resulting in Stillbirth" - New Jersey

What Is Form REG-68?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2012;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form REG-68 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form REG-68 "Request to Place on File a Certificate of Birth Resulting in Stillbirth" - New Jersey

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New Jersey Department of Health
Vital Statistics and Registry
PO Box 370
Trenton, NJ 08625-0370
REQUEST TO PLACE ON FILE A
CERTIFICATE OF BIRTH RESULTING IN STILLBIRTH
Per R. S. 26:6-11 the State Registrar shall establish a Certificate of Birth Resulting in Stillbirth for an unintended, intrauterine
fetal death occurring within the State of New Jersey after a gestational period of 20 or more weeks upon request by the
parents, by completing Section I below. The completed form may be filed with the State Registrar directly by the parents or
through a Licensed Health Care Professional who has completed Section II. Completed forms are to be sent to the State
Registrar at the address listed above.
Licensed health care professionals include, but are not limited to, the following: the doctor who was present at the time of
delivery, the family physician, a bereavement counselor.
Certified copies of certificates of birth resulting in stillbirth are available from the period 1969 to the present. Events which
occurred prior to 1969 were not reported and therefore certificates for events prior to 1969 cannot be provided. Parents may
indicate in Section I that they wish to purchase certified copies via this request. If certified copies are requested, please remit
payment, made payable to “State Registrar” in the amount of $25.00 for the first certificate and $2.00 for each additional copy.
PLEASE DO NOT SEND CASH! Please allow 4 to 6 weeks for processing of your request; the certificate(s) will be mailed to
the address provided in Section I. Future requests for certified copies may be requested at the State Registrar’s Office or the
Office of Vital Records in the municipality where the event occurred. Please include a photocopy of one of the parents’ driver’s
license as proof of identity.
If the record on file indicates that no name was given, the certificate will be issued in the same manner. Parents who wish to
amend the record to add a name may do so by filing a Correction to an Original Birth, Marriage or Death Certificate form
(REG-34) with the State Registrar's Office. Copies of the REG-34 form may be obtained from the Local Registrar’s Office in
your New Jersey municipality, or from the State Registrar's office.
A birth resulting in stillbirth that occurred in the State of New Jersey but has not been registered within one year after the date
of delivery may be placed on file and registered as a delayed report, provided that verifiable proof of the delivery is submitted.
Certified copies of delayed reports shall be noted as Delayed Certificates of Birth Resulting in Stillbirth.
SECTION I - TO BE COMPLETED BY PARENT(S)
Name of Parent(s)
Telephone Number
Mailing Address
City
State
Zip Code
Certified Copy Requested?
Signature of Applicant
Date of Application
No
Yes - Quantity:
INFORMATION ON BIRTH RESULTING IN STILLBIRTH
Full Name, if Given
Name Not Given
Place of Delivery (City, Town or Township)
County
Date of Delivery
Name of Hospital (Optional)
Mother's Full Maiden Name
Name of Other Parent (if recorded on the record)
SECTION II - TO BE COMPLETED IF THE FORM IS SUBMITTED VIA A LICENSED HEALTH CARE PROFESSIONAL
Submitted by (Name of Licensed Health Care Professional) (PRINT)
Telephone Number
Title
FOR STATE USE ONLY
ID Viewed:
Processed By:
Date Processed:
REG-68
JUL 12
New Jersey Department of Health
Vital Statistics and Registry
PO Box 370
Trenton, NJ 08625-0370
REQUEST TO PLACE ON FILE A
CERTIFICATE OF BIRTH RESULTING IN STILLBIRTH
Per R. S. 26:6-11 the State Registrar shall establish a Certificate of Birth Resulting in Stillbirth for an unintended, intrauterine
fetal death occurring within the State of New Jersey after a gestational period of 20 or more weeks upon request by the
parents, by completing Section I below. The completed form may be filed with the State Registrar directly by the parents or
through a Licensed Health Care Professional who has completed Section II. Completed forms are to be sent to the State
Registrar at the address listed above.
Licensed health care professionals include, but are not limited to, the following: the doctor who was present at the time of
delivery, the family physician, a bereavement counselor.
Certified copies of certificates of birth resulting in stillbirth are available from the period 1969 to the present. Events which
occurred prior to 1969 were not reported and therefore certificates for events prior to 1969 cannot be provided. Parents may
indicate in Section I that they wish to purchase certified copies via this request. If certified copies are requested, please remit
payment, made payable to “State Registrar” in the amount of $25.00 for the first certificate and $2.00 for each additional copy.
PLEASE DO NOT SEND CASH! Please allow 4 to 6 weeks for processing of your request; the certificate(s) will be mailed to
the address provided in Section I. Future requests for certified copies may be requested at the State Registrar’s Office or the
Office of Vital Records in the municipality where the event occurred. Please include a photocopy of one of the parents’ driver’s
license as proof of identity.
If the record on file indicates that no name was given, the certificate will be issued in the same manner. Parents who wish to
amend the record to add a name may do so by filing a Correction to an Original Birth, Marriage or Death Certificate form
(REG-34) with the State Registrar's Office. Copies of the REG-34 form may be obtained from the Local Registrar’s Office in
your New Jersey municipality, or from the State Registrar's office.
A birth resulting in stillbirth that occurred in the State of New Jersey but has not been registered within one year after the date
of delivery may be placed on file and registered as a delayed report, provided that verifiable proof of the delivery is submitted.
Certified copies of delayed reports shall be noted as Delayed Certificates of Birth Resulting in Stillbirth.
SECTION I - TO BE COMPLETED BY PARENT(S)
Name of Parent(s)
Telephone Number
Mailing Address
City
State
Zip Code
Certified Copy Requested?
Signature of Applicant
Date of Application
No
Yes - Quantity:
INFORMATION ON BIRTH RESULTING IN STILLBIRTH
Full Name, if Given
Name Not Given
Place of Delivery (City, Town or Township)
County
Date of Delivery
Name of Hospital (Optional)
Mother's Full Maiden Name
Name of Other Parent (if recorded on the record)
SECTION II - TO BE COMPLETED IF THE FORM IS SUBMITTED VIA A LICENSED HEALTH CARE PROFESSIONAL
Submitted by (Name of Licensed Health Care Professional) (PRINT)
Telephone Number
Title
FOR STATE USE ONLY
ID Viewed:
Processed By:
Date Processed:
REG-68
JUL 12