Instructions:

• Complete a separate application for each fetal death record requested.

• 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 the fetal death record does not exist, check box for CPNR (Certificate of No Public Record) Request. If no fetal death record is found, the fee submitted bill be retained for searching for the record ( as required by law H&S Code 103650) and a "Certificate of No Public Record" will be issued to the applicant.