FETAL DEATH Application for Certified Copy of Maryland Fetal Death Record FETAL DEATH
Maryland Department of Health ● Division of Vital Records
By my signature below, I state that I am the person I represent myself to be herein, and I affirm that the information submitted on this form is
complete and accurate and submitted subject to the criminal penalties set forth at Maryland Code Annotated, Health-General Section 4-227.
Signature of person making request: __________________________________________________
Date of Application: ______________________________________________________________
PRINT or TYPE your name & CURRENT address.
Your relationship to the person
Name: _______________________________________________________ named on the Certificate: _____________________________
Address: ________________________________________________________________________________________________________
City: _______________________________________________________________ State: ____________________ Zip: _____________
Daytime phone number: (______) ________- ___________ E-mail Address: __________________________________________
PHOTO ID REQUIRED: The individual requesting the record should submit a legible copy of his/her VALID GOVERNMENT-
ISSUED PHOTO ID with completed application. (Examples: State issued driver’s license or non-driver photo ID with requestor’s
current address; passport). If you do not have a Government-issued photo ID, read and sign the following statement: I declare that I
do not have a government-issued photo ID and that I am presenting the attached two documents that include my name and current
address as proof of identification. (Note: These documents must include two of the following: Utility bill, car registration form, pay
stub, bank statement, copy of income tax return/W-2 form, letter from a government agency requesting a vital record, or lease/rental
agreement. Please submit photocopies since these documents will not be returned to you. If you do not have a Government-issued photo
ID, the certificate(s) will be mailed to the address listed on the documents that you present.)
Signature: ______________________________________________________________________
Name at Delivery: ___________________________________________________________________________________________
Date of Delivery: __________________________ Sex: □ Female □ Male
(Month/Day/Year)
Place of Delivery:
________________________ Hospital: ____________________ Certificate No. (if known) __________
(County or Baltimore City)
Full Maiden Name of Mother: _________________________________________________________________________________
Full Name of Father: __________________________________________________________________________
ORDER INFORMATION
A non–refundable $12 fee is required for each copy of a certificate.* Send check or money order. Do not
send cash when applying by mail. When paying by check, you must include a copy of your driver’s license
or other government-issued photo ID that lists your current address, or other acceptable ID as noted above.
When ordering by mail, send completed application, legible copy of ID, a self-addressed, stamped envelope,
and check or money order payable to the DIVISION OF VITAL RECORDS to the Division of Vital Records,
P.O. Box 68760, Baltimore, Maryland 21215-0036.
You may also apply for a fetal death record in person or online. For further information, visit the Vital
Statistics Administration website at www.health.maryland.gov/vsa.
*There is no fee for a copy of a certificate of a child of a current or former armed forces member if the copy
will be used in connection with a claim for a dependent or beneficiary of the member. Proof of service in the
armed forces must be provided.
Number of
certificates
requested
Fee per
copy*
x $12.00
Amount
enclosed
Rev. 10/21
NOTE: A copy of a fetal death record may only be issued to a parent named on the Certificate; a representative with a notarized letter
signed by a parent granting permission to obtain a Certificate, or an individual with a court order directing that the Certificate be issued.
For Issuing Office Only
Photo
ID
Mailed
