Type or Print in

PERMANENT INK

See Hospital and

REGISTRATION DISTRICT NO

REGISTERED NUMBER

STATE OF ILLINOIS

STATE FILE

NUMBER

Funeral Directors

Handbooks for

CERTIFICATE OF FETAL DEATH

INSTRUCTIONS

FETUS-NAME

FIRST

MIDDLE

LAST

DATE OF DELIVERY  (MONTH  DAY  YEAR)

HOUR

1.

2a.

2b.

M

FETUS

SEX

COUTY OF DELIVERY

CITY, TOWN, TWP OR ROAD DISTRICT NO

HOSPITAL –NAME (IF NOT HOSPITAL GIVE STREET AND NUMBER)

3.

4a.

4b.

4c.

MOTHER-MAIDEN NAME

FIRST

MIDDLE

LAST

DATE OF BIRTH (MONTH DAY YEAR)

BIRTHPLACE

(STATE OR FOREIGN COUNTRY)

5c.

MOTHER

5a.

5b.

RESIDENCE - STREET AND NUMBER OR RFD

CITY, TOWN, TWP OR ROAD DISTRICT NO

INSIDE CITY

(YES     NO)

COUNTY

STATE

ZIP CODE

6a.

6b.

6c.

6d.

6e.

6f.

FATHER

FATHER - NAME

FIRST

MIDDLE

LAST

DATE OF BIRTH (MONTH DAY YEAR)

BIRTHPALCE

(STATE OR FOREIGN COUNTRY)

7a.

7b.

7c.

INFORMANT'S SIGNATURE

RELATIONSHIP

MAILING ADDRESS (STREET AND NO. OR R.F.D. CITY OR TOWN, STATE AND ZIP)

8a.►

8b.

8c.

9. PART 1 FETAL DEATH WAS CAUSED BY

(ENTER ONLY ONE CAUSE PER LINE FOR (a), (b) AND (c))

SPECIFY FETAL OR MATERNAL

FETAL OR MATERNAL

CONDITION DIRECTLY

CAUSING FETAL DEATH

IMMEDIATE CAUSE

{

(a)

DUE TO OR AS A CONSEQUENCE OF

FETAL AND OR MATER-

NAL CONDITIONS, IF ANY,

GIVING RISE TO THE

IMMEDIATE CAUSE (a),

STATING THE UNDERLY-

ING CAUSE LAST

{

CAUSE

(b)

DUE TO OR AS A CONSEQUENCE OF

(c)

PART II  OTHER SIGNIFICANT CONDITIONS OF FETUS OR MOTHER CONTRIBUTING TO FETAL DEATH BUT NOT RESULTING IN THE UNDERLYING CAUSE GIVEN IN PART I

FETUS DIED BEFORE LABOR, DURING LABOR OR DELIVERY UNKNOWN (SPECIFY)

AUTOPSY

(YES    NO)

WERE AUTOPSY FINDINGS AVAILALE PRIOR TO COMPLETION OF CAUSE OF DEATH? (YES NO)

10.

11a.

11b.

I CERTIFY THAT THIS FETUS WAS BORN DEAD AT THE PLACE AND TIME ON THE DATE STATED ABOVE

DATE SIGNED (MONTH DAY YEAR)

ATTENDANT – M.D., D.O., MIDWIFE, OTHER (SPECIFY)

SIGNATURE

CERTIFIER

12a. ►

12b.

12c.

CERTIFIER'S COMPLETE MAILING ADDRESS (STREET AND NO OR R.F.D., CITY OR TOWN, STATE, ZIP)

ILLINOIS LICENSE NUMBER

12d.

13.

BURIAL, CREMATION, OR REMOVAL

CEMETERY OR CREMATORY – NAME

LOCATION (CITY OR TOWN, STATE)

DATE (MONTH DAY YEAR)

(SPECIFY)

14a.

14b.

14c.

14d.

FUNERAL  HOME

NAME

STREET AND NUMBER OR R.F.D.

CITY OR TOWN

STATE

ZIP

15a.

DISPOSITION

FUNERAL DIRECTOR'S SIGNATURE

FUNERAL DIRECTOR'S ILLINOIS LICENSE NUMBER

15b.

15c.

LOCAL REGISTRARS SIGNATURE

DATE FILED BY LOCAL  REGISTAR    (MONTH, DAY, YEAR)

16a.   ►

16b.

VR-110-(11/89)

INFORMATION FOR HEALTH AND STATISTICAL USE ONLY

(BASED ON 1989 U.S. STANDARD CERTIFICATE)

OF HISPANIC ORGIN?

RACE-American Indian,

19. EDUCATION

20. OCCUPATION AND BUSINESS/INDUSTRY

(Specify below No or Yes-If Yes

specify Cuban, Mexican, Puerto Rican, etc.)

Black, White, etc.

(Specify only highest grade completed)

(Worked during last year)

(Specify below)

Elementary/Secondary (0-12)

College (1-4 or 5+)

Occupation

Business/Industry

17.

18.

No

Yes

MOTHER

17a.

Specify:

18a.

19a.

20a.

20b.

No

Yes

FATHER

17b.

Specify:

18b.

19b.

20c.

20d.

21.  PREGNANCY HISTORY

(Complete each section)

MOTHER MARRIED? at delivery, conception or at 

DATE LAST NORMAL MENSES BEGAN

any time between (Yes or No)

(Month, Day, Year)

22.

23.

LIVE BIRTHS

OTHER TERMINATIONS

(Spontaneous and induced at

any time after conception)

MONTH OF PREGNANCY PRENATAL CARE BEGAN

PRENATAL VISTS

First,   Second,   Third,   Etc.     (Specify)

Total Number (if none so state)

24.

25.

NOW LIVING

NOW DEAD

(Do Not Include This Fetus)

WEIGHT OF FETUS

CLINICAL ESTIMATE OF GESTATION

Number

Number

Number

(Specify Units)

21a.    None

21b.    None

21d.     None

26.

27.

Weeks

DATE OF LAST LIVE BIRTH

DATE OF LAST OTHER TERMINATION

PLURALITY

IF NOT SINGLE BIRTH - Born

(Month, Year)

(Month, Year)

Single, Twin, Triplet, etc. (Specify)

First, Second, Third, etc.     (Specify)

21c.

21e.

28a.

28b.

DATE OF MOTHER'S BLOOD TEST FOR SYPHILIS (Month  Day  Year)

LABORATORY DOING THE SEROLOGY

29a.

29b.

30a.

MEDICAL RISK FACTORS FOR THIS PREGNANCY

(Check all that apply)

32.

OBSTETRIC PROCEDURES

(Check all that apply)

34.

CONGENITAL ANOMALIES OF

FETUS (Check all that apply)

Anemia (Hct.<30/Hgb. <10).............................................

01

Amniocentesis......................................................

01

Anencephalus............................................

01

Cardiac disease.............................................

02

Electronic fetal monitoring......................

02

Spina bifida/Meningocele.............

02

Acute or chronic lung disease.........................................

03

Induction of labor...................................................

03

Hydrocephalus..........................................

03

Diabetes.......................................................................

04

Stimulation of labor................................

04

Microcephalus.............................

04

Genital herpes...............................................................

05

Tocolysis..............................................................

05

Other central nervous system anomalies

Hydramnios/Oligohydramnios.......................

06

Ultrasound............................................

06

(Specify) ___________________________

05

Hemoglobinopathy...................................................

07

None.....................................................................

00

Heart malformations.....................

06

Hypertension, chronic..................................

08

Other (specify)_____________________

07

Other circulatory/respiratory anomalies

Hypertension, pregnancy associated..............................

09

(Specify) ___________________________

07

Eclampsia......................................................

10

33.  COMPLICATIONS OF LABOR

Rectal atresia/stenosis.................

08

Incompetent cervix........................................................

11

AND/OR DELIVERY (Check all that apply)

Tracheo-esophageal fistula/

Previous infant 4000 + grams..........................

12

Febrile (>100°F. or 38°C.)......................................

01

Esophageal atresia....................................

09

Previous preterm or small-for-gestational-age infant.........

13

Meconium, moderate, heavy..................................

02

Omphalocele/Gastroschisis..........

10

Renal disease.................................................

14

Premature rupture of membrane (>12 hours)

03

Other gastrointestinal anomalies

Rh sensitization............................................................

15

Abruptio placenta..................................

04

(Specify) ___________________________

11

Uterine bleeding.............................................

16

Placenta previa.....................................................

05

Malformed genitalia......................

12

None.............................................................................

00

Other excessive bleeding.......................................

06

Renal agenesis..........................................

13

Other (specify) ________________________

17

Seizures during labor.............................................

07

Other urogenital anomalies

Precipitous labor (<3hours)....................................

08

(Specify) __________________

14

30b.  OTHER RISK FACTORS FOR THIS

Prolonged labor (>20 hours)....................................................

09

Cleft lip/palate............................................

15

PREGNANCY (Complete all items)

Dysfunctional labor................................................

10

Polydactyly/Syndactyly/Adactyly...

16

Tobacco use during pregnancy........................

Yes

No

Breech/Malpresentation.........................................

11

Club foot....................................................

17

Average number of cigarettes per day ___

Cephalopelvic disproportion...................

12

Diaphragmatic hernia...................

18

Alcohol use during pregnancy..........................

Yes

No

Cord prolapse.......................................................

13

Other musculoskeletal/integumental anomalies

Average number drinks per week _____

Anesthetic complications.......................

14

(Specify) ___________________________

19

Weight gain during pregnancy _____ lbs.

Fetal Distress........................................................

15

Down's syndrome........................

20

None.....................................................

00

Other chromosomal anomalies

31.  METHOD OF DELIVERY (Check all that apply)

Other (specify)......................................................

16

(Specify) ___________________________

21

SOCIAL SECURITY NUMBER

None............................................

00

Vaginal.........................................................................

01

MOTHER

Other (specify)  _____________________

22

Vaginal birth after previous C-section...............

02

35.

Primary C-section.........................................................

03

SOCIAL SECURITY NUMBER

Repeat C-section ...........................................

04

FATHER

Forceps........................................................................

05

36.

Vacuum..........................................................

06

Hysterotomy/Hysterectomy............................................

07