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General Instructions for Completing Stillbirth Certificates

  • Use the current Oklahoma Certificate of Stillbirth form designated by the State of Oklahoma. (VS 153 2009)
  • Complete each required item. 
  • Make the entry legible.  Use a computer printer with high resolution, typewriter with good black ribbon and clean keys, or print legibly using permanent black ink.
  • Avoid abbreviations when possible.  If you must use abbreviations, use standard abbreviations (ex. US Postal Service abbreviations for addresses).
  • Verify the spelling of names, especially those that have different spellings for the same sound.
  • Obtain all signatures.  THEY MUST BE ORIGINAL.  Rubber stamps or other facsimile signatures are not acceptable. 
  • Do not make alterations or erasures.
  • File the original certificate with the State Registrar.  Reproductions or duplicates are not acceptable. 
  • Refer problems to the Vital Records Division. 

Completing the Certificate of Stillbirth

These instructions pertain to the 2009 Revision of the State of Oklahoma Certificate of Stillbirth (Form VS 153 2009). 

For all items on the stillbirth certificate, including in the Medical Information section, "unknown" is an entry option.  However, please understand that this should be the exception and not the common practice!  Every attempt should be made to obtain the information requested for record submission. 

All required items must be completed.  If there are required items left blank on the certificate, it will be rejected in accordance with Oklahoma Administrative Code 310:105-1-2(1).

Item 1.  Name (First, Middle, Last, Suffix) - Optional at the discretion of the parents

Enter the full name given to the fetus.  If the parents chose not to name the fetus, enter "Baby Boy" or "Baby Girl" (whichever is appropriate) as the fetus' first name and the mother's last name as the fetus' last name.

Item 2.  Time of Delivery

Enter the time of delivery.  If the time of delivery is not known, enter "Unknown" in the space.  Do not leave this item blank. 

Item 3.  Sex (M/F/Unk)

Enter male or female based on observation or verification with medical records.  Do not use symbols.  If sex cannot be determined after verification with medical records or other sources, enter "Unknown."  Do not leave this item blank. 

Item 4.  Date of Delivery (Month, Day, Year)

Enter the exact month, day, and year that the fetus was delivered. 

Item 5a.  Place Where Delivery Occurred (Check one)

Check box that best describes the type of place where the stillbirth occurred.  If the type of place is not known, enter "Unknown.”  Do not leave this item blank. 

Item 5b.  Facility Name: If not institution, give street and number

Enter name of facility where stillbirth occurred.  If it did not occur in a hospital or freestanding birthing center, enter street and number of the place where stillbirth occurred.  If stillbirth occurred in a moving conveyance, enter city, town, village, or other location where fetus was first removed from the conveyance. 

Item 5c.  Facility ID (NPI)

Enter facility's National Provider Identification number (NPI). 

Item 5d.  City, Town, or Location of Delivery

Enter the name of the city, township, village, or other location where the stillbirth occurred.  For stillbirths occurring on a moving conveyance, enter the city, town, village, or location where the fetus was first removed from the conveyance.

If a dead fetus is found and the place of the stillbirth is unknown, the place where the fetus was found should be considered the place of stillbirth.

Item 5e.  ZIP Code of Delivery

Enter the ZIP Code of the city where the stillbirth occurred.

Item 5f.  County of Delivery

Enter the name of the county where the stillbirth occurred.  For stillbirths occurring on a moving conveyance, enter the county where the fetus was first removed from the conveyance. 

Item 6a.  Mother's Current Legal Name (First, Middle, Last, Suffix)

Enter the first, middle, and last name of the mother at the time of delivery. 

Item 6b.  Mother's Last Name Prior to First Marriage

Enter mother's last name used prior to first marriage, commonly known as the maiden name. 

Item 6c.  Mother's Date of Birth (Month, Day, Year)

Enter the month, day, and year that the mother was born.

6d.  Mother's Birthplace (State, Territory, or Foreign Country)

Enter the name of the U.S. State or territory in which the mother was born.  United States territories are Puerto Rico, U.S. Virgin Islands, Guam, American Samoa, and Northern Marianas. 

If the mother was born outside of the United States, enter the name of the country in which she was born. 

Item 6e.  Mother's Residence Address

The mother's residence is the place where her household is located.  This is not necessarily the same as her home State, voting residence, mailing address, or legal residence.  The State, county, city, and street address should be for the place where the mother actually lives. 

If mother had been living in a facility where an individual usually resides for a long period of time, such as a group home, mental institution, nursing home, penitentiary, or hospital for chronically ill, this facility should be entered as the place of residence. 

Enter the number and street name of the place where the mother lives.  Enter the apartment number if applicable, otherwise leave blank. 

Enter the name of the city, town, or location where the mother lives. 

Enter the name of the State in which the mother lives.  If the mother is not a U.S. resident, enter the name of the country and the name of the unit of government that is the nearest equivalent to a State. 

Enter the ZIP Code of the place where the mother resides. 

For "Inside City Limits?" check "Yes" if the location entered in Item 8 for mother's residence is incorporated and the mother's residence is inside its boundaries.  Otherwise check "No."

Enter the name of the county in which the mother lives. 

Item 7a.  Father's Current Legal Name (First, Middle, Last, Suffix)

If the fetus was born to a mother who was married at the time of the delivery, enter the name of the husband. 

If fetus was conceived in wedlock but delivered after a divorce was granted or after the husband died, enter name of  mother's deceased or divorced husband.

If the fetus was conceived and delivered out of wedlock to a divorced, widowed, or never-married mother, leave this item blank.

Item 7b.  Father's Date of Birth (Month, Day, Year)

Enter the month, day, and year that the father was born. 

If Item 7a is left blank, then leave this item blank also. 

Item 7c.  Father's Birthplace (State, Territory, or Foreign Country)

Enter name of U.S. State or territory in which the father was born.  United States territories are Puerto Rico, U.S. Virgin Islands, Guam, American Samoa, and Northern Marianas. 

If father was born outside of the United States, enter name of country in which he was born. 

Item 8a.  Attendant's Name, Title and NPI

The hospital or birthing facility should complete this item. 

The attendant is the person present at the delivery who is responsible for the delivery.  Please print or type the name of the attendant and their NPI number.  If the attendant does not have an NPI number, type or print "none."  If the attendant should have an NPI number but it is unknown, type or print "unknown."

Check the appropriate box for the attendant’s title.

Item 8b.  Certification Statement and Signature

The hospital or birthing facility completes this item.

Obtain signature of the attendant whose name is entered in Item 8a.

Item 8c.  Date Certified (Month, Day, Year)

The attendant should complete this item after signing Item 8b.

Type or print month, day, and year that attendant in Item 8b signed certificate. 

Item 9.  Method of Disposition

Check the box corresponding to the method of disposition of the fetus.  If "Other (Specify)" is checked, enter the method of disposition on the line provided.  If fetus is to be used by a hospital or a medical or mortuary school for scientific or educational purposes, enter "Donation."  Donation refers only to the entire fetus, not to individual organs. 

Item 10a.  Funeral Home

Enter the name of the facility handling the fetus prior to burial or other disposition. 

Enter name of funeral service licensee or other person first assuming custody of the fetus and responsible for completing the stillbirth certificate. 

Item 10b.  Funeral Home Mailing Address

Enter the complete address (including ZIP Code) of the facility handling the fetus prior to burial or other disposition. 

Item 11.  Registrar's Signature

To be used by the State Registrar only.

Item 12.  Date Filed With Registrar (Month, Day, Year)

To be used by the State Registrar only.

The following items on the stillbirth certificate make up the “Confidential Information for Medical and Health Use Only” section.  It is to be completed by the medical facility.  Leave no items blank unless otherwise instructed.

Item 13a.  Initiating Cause/Condition

Select one choice most likely to have begun the sequence of events resulting in the death of the fetus.  Specify when appropriate or possible. 

Item 13b.  Other Significant Causes or Conditions

Select all other conditions contributing to the death indicated in Item 13a. 

Item 13c.  Estimated Time of Fetal Death

Indicate when the fetus died by specifying one choice. 

Item 13d.  Obstetrical Estimate of Gestation at Delivery

Enter the obstetric estimate of the fetus' gestation. 

If the obstetric estimate of gestation is unknown, print or type "unknown" in the space.  Do not complete this item based on the fetus' date of delivery and the patient's date of last menstrual period. 

Item 13e.  Weight of Fetus (specify unit, grams preferred)

Report weight of fetus.  If birth weight is not known, enter "unknown."

Item 13f.  Was an Autopsy Performed?

Enter "Yes" if partial or complete autopsy was performed.  Otherwise enter "No."'

Item 13g.  Was a Histological Placental Examination Performed?

Enter "Yes" if a histological placental examination was performed.  Otherwise enter "No."

Item 13h.  Were Autopsy or Histological Placental Examination Results Used in Determining the Cause of Fetal Death?

If "No" is checked for both Item 13f and Item 13g, then leave this item blank.  If "Yes" is checked for either Item 13f or Item 13g, then complete this item by checking the appropriate box.

Item 14a.  Father's Education (Check the box that best describes the highest degree or level of school completed at the time of delivery)

If father is currently enrolled, mark the previous grade or highest degree received. 

Item 14b.  Father of Hispanic Origin? (Check the box that best describes whether the father is Spanish/Hispanic/Latino.  Check the ‘No’ box if father is not Spanish/Hispanic/Latino)

Based on the patient's response, enter all the corresponding boxes and fill in any literal (written) responses.  Encourage patient to select only one response.  If patient chooses more than one response, check all that is selected.  If patient indicates an ethnic origin not on the list, record it in the "Specify" space.  Enter patient's response in this space even if it is not a Hispanic origin. 

Ask the Hispanic Origin question and Race question independently.  "Hispanic" is not a race.  A person of Hispanic origin may be of any race.  "Hispanic" is a self-designated classification for people whose origins are from Spain, Spanish-speaking countries of Central or South America, the Caribbean, or those identifying themselves generally as Spanish or Spanish American.  Origin can be viewed as ancestry, nationality, country of birth, or the person or person's parents or ancestors prior to their arrival in the United States.  Although the prompts include the major Hispanic groups, other groups may be specified under "Other." 

Do not leave Item 14b blank.

Item 14c.  Father's Race

Based on the patient's response, select all the corresponding boxes and fill in any literal (written) responses exactly as given regardless of whether or not any boxes are marked.  If more than one response has been chosen, check all selected.  If there is no response, type or print "unknown."

American Indian and Alaska Native refer only to those native to North and South America (including Central America) and do not include Asian Indian.  Specify the name of enrolled or principal tribe (e.g., Navajo or Cheyenne) for the American Indian or Alaska Native. 

Do not leave Item 14c blank.

Item 15a.  Mother's Education

Check box corresponding to the highest level of education the mother completed. 

If mother is currently enrolled, mark the previous grade or highest degree received. 

Item 15b.  Mother of Hispanic Origin?

Based on the patient's response, enter all the corresponding boxes and fill in any literal (written) responses.  Encourage patient to select only one response.  If patient chooses more than one response, check all that is selected.  If patient indicates an ethnic origin not on the list, record it in the "Specify" space.  Enter patient's response in this space even if it is not a Hispanic origin. 

Ask the Hispanic Origin question and Race question independently.  "Hispanic" is not a race.  A person of Hispanic origin may be of any race.  "Hispanic" is a self-designated classification for people whose origins are from Spain, Spanish-speaking countries of Central or South America, the Caribbean, or those identifying themselves generally as Spanish or Spanish American.  Origin can be viewed as ancestry, nationality, country of birth, or the person or person's parents or ancestors prior to their arrival in the United States.  Although the prompts include the major Hispanic groups, other groups may be specified under "Other." 

Do not leave Item 15b blank.

Item 15c.  Mother's Race

Based on the patient's response, select all the corresponding boxes and fill in any literal (written) responses exactly as given regardless of whether or not any boxes are marked.  If more than one response has been chosen, check all selected.  If there is no response, type or print "unknown."

American Indian and Alaska Native refer only to those native to North and South America (including Central America) and do not include Asian Indian.  Specify the name of enrolled or principal tribe (e.g., Navajo or Cheyenne) for the American Indian or Alaska Native. 

Do not leave Item 15c blank.

Item 16.  Mother Married? (At delivery, conception or any time between)

If the patient is currently married or married at time of conception or any time between conception and the stillbirth, check the "Yes" box. 

If the patient is not currently married or was not married at the time of conception or any time between conception and the stillbirth, check the "No" box. 

Item 17.  Date of First Prenatal Care Visit

Prenatal care begins when a physician or other health professional first examines and/or counsels the pregnant woman as part of an ongoing program of care for the pregnancy.

Enter the month, day, and year of the first prenatal care visit. 

If it is not known whether the patient had prenatal care, or if she had care but the date of the first visit is not know, enter "unknown."

If the patient had no prenatal care, check the "no prenatal care" box and leave the date blank.

Item 18.  Date of Last Prenatal Care Visit

Enter the date of the last visit recorded in the patient's prenatal records. 

If it is not known whether the patient had prenatal care, or if she had care but the date of the last visit is not known, enter "unknown."

If the patient had no prenatal care, leave the date blank.  The "no prenatal care" box should also be checked in Item 16.

Item 19.  Total Number of Prenatal Care Visits for this Pregnancy

If the patient had no prenatal care, enter "0" in the space.  The "no prenatal care" box should also be checked in Item 16. 

If the patient had prenatal care but the number of visits is not known, enter "unknown" in the space.

Enter the total number of prenatal care visits for this pregnancy in this space.

Item 20.  Did Mother Get WIC Food For Herself During This Pregnancy?

This item is to be completed based on information obtained from the patient.  Either check "Yes" or "No."  Do not leave this item blank. 

Item 21.  Mother's Height

Enter the patient's height at the time of delivery.  If the patient's height is unknown, enter "unknown" in the space.

Item 22.  Mother's Pre-Pregnancy Weight

If the patient's pre-pregnancy weight is unknown, enter "unknown" in the space.

Item 23.  Mother's Weight at Delivery

If the patent's delivery weight is unknown, enter "unknown" in the space.

Item 24.  Date Last Normal Menses Began

Enter the date that the patient's last normal menses began. 

If the date is not known, enter "unknown."

Item 25.  Plurality

Enter the plurality of this pregnancy.  Include all products of the pregnancy, that is, all live births and stillbirths delivered at any point during the pregnancy.  "Reabsorbed" fetuses, those which are not "delivered" - expulsed or extracted from the patient - should not be counted.

Item 26.  If Not Single Birth

If this is a single delivery, leave this item blank.  For multiple deliveries, enter the order that this fetus was delivered in the set.  Count all live births and stillbirths at any point in the pregnancy. 

Item 27.  Cigarette Smoking (For each period, enter either the number of cigarettes or the number of packs of cigarettes smoked-IF NONE, ENTER 0)

This item is to be completed by the facility based on information obtained from the patient.  If the delivery did not occur in a facility, it is to be completed by the attendant or certifier based on information obtained from the patient. 

If the patient does not provide an answer to this item, enter "unknown."  Enter either the average number of cigarettes or the average number of packs of cigarettes smoked for each time period.  If none, enter "0."

Item 28.  Pregnancy History (Do not include this child)

When completing the number of previous live births now living, do not include this stillbirth; include all previous live-born infants.  For multiple deliveries, include all live-born infants preceding this stillbirth in the delivery.  If first delivered in a multiple delivery, do not include this fetus.  If second delivered, include the first live born, etc.

When completing the number of previous live births now dead, do not include this stillbirth but include all previous live-born infants who are now dead.

Enter the date of the last live birth. 

When completing the number of other pregnancy outcomes, include fetal losses of any gestational age - spontaneous losses, induced losses, and/or ectopic pregnancies.  If this was a multiple delivery, include all fetal losses delivered before this fetus in the pregnancy. 

Enter the date of the last other pregnancy outcome. 

If there is no pregnancy history, enter "0" in each space and leave both dates blank.

Item 29.  Risk Factors in This Pregnancy (Check all that apply)

The patient may have more than one risk factor; check all that apply.  If the patient had none of the risk factors, check the "none of the above" box. 

Item 30.  Infections Present and/or Treated During This Pregnancy (Check all that apply)

Present at start of pregnancy or confirmed diagnosis during pregnancy with or without documentation of treatment.

If the prenatal record is not available and the information is not available from other medical records, enter "unknown" in the space.  More than one infection may be checked. 

Item 31.  Congenital Anomalies of the Fetus (Check all that apply)

Malformations of the fetus diagnosed prenatally or after delivery.  Check all that apply.

Anomalies diagnosed should be recorded regardless of whether they contributed to stillbirth. 

Item 32.  Method of Delivery

The physical process by which the complete delivery of the fetus was effected.  A response to each section is required.

If any of the information for an individual section is not known at this time, enter "unknown" in the space for that particular section.

Item 33.  Maternal Morbidity (Complications associated with labor and delivery) (Check all that apply)

Serious complications experienced by the patient associated with labor and delivery.  Check all that apply.

Item 34.  Was Mother Transferred for Maternal Medical or Fetal Indications for Delivery?

Transfers include hospital-to-hospital, birth facility-to-hospital, etc.

Check "Yes" if the patient was transferred from another facility to this one, and enter the name of the facility. 

Once You're Finished . . .

The funeral director should immediately review the certificate for completeness and accuracy once it is received from the medical certifier.  If there is a problem with the medical items of the certificate, the funeral director should immediately bring it to the attention of the physician.

Remember, the funeral director is responsible for filing an accurate and complete Oklahoma Certificate of Stillbirth.

When the stillbirth certificate is complete, file it with the State Registrar. 

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