General Information

Fetal Death Registration

General Information Chapter 1

Purpose

The purpose of this handbook is to acquaint persons responsible for the registration of fetal

deaths with the vital registration system in Texas and to provide instructions for completing

and filing fetal death certificates.

A fetal death certificate is a permanent legal record of the fact of death. Because the

information contained within the record is considered to be prima facie evidence of the fact of

death, it may be introduced in court as evidence when a question about the death arises.

Further, the fetal death certificate is needed for a variety of medical and health-related

research efforts. The information on the fetal death certificate is used to study the causes of

adverse pregnancy outcomes and these data are essential in planning and evaluating

prenatal care services and obstetric programs. These data are also used to examine the

consequences to the fetus of possible environmental and occupational exposures of the

parents.

Because the information derived from fetal death certificates can be no more accurate than

the data on the certificate, it is very important that all persons concerned with the registration

of fetal deaths strive not only for complete registration but also for accuracy and promptness

in reporting these events.

Registration Requirements

For every fetal death weighing 350 grams or more, or if the weight is unknown, a fetus aged

20 weeks or more as calculated from the start date of the last normal menstrual period to the

date of delivery, a Certificate of Fetal Death (Form VS-113) must be filed within five (5) days

of the death with the local registrar of the district in which the fetal death occurred or the

fetus was found. [25 TAC §181.7] Instructions for completing the Certificate of Fetal Death

are found in Chapter 2 of this handbook.

Registration of a fetal death is not required in Texas if the weight is under 350 grams or if the

weight is unknown, the period of gestation is less than 20 completed weeks. The weight of

the fetus or, if the weight is unknown, length of gestation is determined by the physician,

medical examiner or justice of the peace, as the case may be. When a pregnant woman dies

a fetal death certificate is required only if the fetus is removed from the mother’s body and

the fetus weighs 350 grams or more, or if the weight is unknown, a period of gestation of 20

completed weeks or more at the time of the mother’s death.

A Report of Death (Form VS-115) must also be filed with the local registrar within 24 hours of

taking custody of a fetus by the funeral director or other person acting as such who first

assumes custody of the fetus. [25 TAC §181.2(a)] Instructions for completing the Report of

Death form are found in Chapter 3 of this handbook.

Fetal Death Vs. Infant Death

In order to understand when to file a Certificate of Fetal Death, it is important to recognize

the difference between a fetal death, a live birth, and an infant death. A fetal death is a death

that occurred before labor or during labor or delivery. An infant death is a death that occurred

after delivery, up to one year of age.

A Certificate of Fetal Death is filed when a delivery weighing 350 grams or more, or if the

weight is unknown, a fetus aged 20 weeks or more as calculated from the start date of the

last normal menstrual period to the date of delivery results in a fetus that shows no evidence

of life. The fetal death is indicated by the fact that after complete expulsion or extraction from

the mother, the fetus does not breathe or show any other evidence of life, such as beating of

the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles,

regardless of whether the umbilical cord has been cut or the placenta is attached. [25 TAC

§181.1 (11)]

If there are any signs of life after delivery (breathing, beating of the heart, pulsation of the

umbilical cord, or definite movement of voluntary muscles), whether or not the umbilical cord

has been cut or the placenta is attached, this event is a live birth. [25 TAC §181.1(18)] A

Certificate of Birth must be filed, even if the infant lives for only a very short period of time,

regardless of the weight or length of gestation or the infant’s chances of survival. If the infant

dies after delivery, a standard death certificate must also be filed.

Fetus or Infant Found Dead

When an abandoned infant or fetus is found dead, a question may arise as to whether the

event should be registered as a fetal death, or as a live birth followed by an infant death. The

case must be referred to the medical examiner or justice of the peace for investigation and

certification because the body was found abandoned. If the medical examiner or justice of

the peace believes that the infant died prior to delivery, and the weight of the fetus is at least

350 grams or more, then the death must be registered using the Certificate of Fetal Death.

If the medical examiner or justice of the peace believes that the infant lived after delivery,

even if only for a short time, then the death should be registered using the standard

Certificate of Death, regardless of the weight. The medical examiner or justice of the peace

must also ensure that the birth of the infant is registered using the Certificate of Birth. The

fetal death certificate or death certificate must be filed with the local registrar in the

registration district in which the fetus or infant was found.

Who Must File a Fetal Death Certificate

The fetal death certificate must be filed by the person in charge of interment or disposition of

the body, or by the person in charge of removal of the body from the registration district for

disposition. [HSC §193.002] If arrangements for disposition of the fetus are made through a

funeral home, the funeral director should complete the fetal death certificate, with input from

the institution where the delivery occurred and the attending physician. If the fetus has been

surrendered to the hospital or birthing center for disposition, the institution is solely

responsible for completing and filing the Certificate of Fetal Death.

The person responsible for filing the fetal death certificate must obtain the required

information from the person or source best qualified to provide the information. Fetal death

registration therefore requires the cooperative efforts of the funeral director or other person

accepting responsibility for disposition of the fetus; the physician who provided care for the

mother; the facility in which the delivery occurred; and the certifier of the cause of fetal death,

who may be the physician who attended the delivery, or the medical examiner or justice of

the peace, according to the circumstances of the fetal death.

Generally, the physician who attended the delivery completes the cause of fetal death. The

medical examiner or justice of the peace must determine the cause of fetal death if:

the fetus was found abandoned and the cause and circumstances of the death are

unknown;

the fetal death is believed to have been due to an accident, suicide, or

homicide; the fetal death occurred in prison or in jail; the fetal death occurred

without having been attended by a physician; the physician is unable or

unwilling to certify the cause of fetal death; or

the circumstances of the fetal death are otherwise properly referable for inquest

[HSC §193.005, CCP Art. 49.04, CCP Art. 49.25 Sec.6].

A midwife or certified nurse-midwife may be listed as an attendant on the fetal death

certificate; however they may not be listed as the certifier. Only a physician, medical

examiner, or justice of the peace may be listed as the certifier on a fetal death certificate. In

some cases the county judge may certify the delivery and when the justice of the peace is

not available to conduct an inquest. The county judge should be notified only in cases that

require an inquest. [CCP Art. 49.07(C)]

Certificate of Birth Resulting in Still Birth

If a fetal death certificate is to be filed, the person required to file the fetal death certificate

must advise the parent(s) that they may, but are not required to, request the preparation of a

Certificate of Birth Resulting in Stillbirth. This commemorative certificate may be obtained by

contacting the State Vital Statistics Section. The person required to file the fetal death

certificate will advise the parent(s) of how to obtain this certificate [HSC §192.0022]. To

request a commemorative certificate, the parent(s) should complete an Application for

Certificate of Birth Resulting in Stillbirth (Form VS-301).

Duties of the Funeral Director or Other Person Accepting

Responsibility for Disposition of the Fetus

Duties of the person accepting responsibility for disposition of the fetus include:

File a Report of Death with the local registrar within 24 hours of taking custody of the

fetus.

Complete, or have completed, all items on the fetal death certificate, obtaining the

required information from the person best qualified to furnish the information.

Give the parent(s) the information on the Certificate of Birth Resulting in Stillbirth.

Notify the medical examiner or coroner for investigation and cause of death

certification, if any of the following circumstances exist [HSC §193.005, CCP Art.

49.04, CCP Art. 49.25 Sec.6]:

1. the fetus was found abandoned and the cause and circumstances of the death

are unknown,

2. the fetal death is believed to have been due to an accident, suicide, or

homicide,

3. the fetal death occurred in prison or in jail,

4. the fetal death occurred without having been attended by a physician,

5. the physician is unable or unwilling to certify the cause of fetal death, or

6. the circumstances of the fetal death are otherwise properly referable for

inquest Cooperate with pathologists in cases involving autopsies.

Secure the signature and the cause of fetal death information from the physician who

attended the delivery, or the medical examiner or the coroner, as appropriate based

upon the circumstances of the fetal death.

Review the certificate for completeness and accuracy.

File the fetal death certificate with the local registrar within five (5) days of death.

Obtain and use all necessary permits and other forms associated with the fetal death

registration process (e.g., Burial-Transit Permit, Disinterment Permit).

Cooperate with the State Vital Statistics Office and local registrars concerning

queries on certificate entries.

Call on the local registrar or the State Vital Statistics Office for advice and assistance

when necessary.

Responsibilities of The Hospital or Other Delivering

Institution

If the fetus has been surrendered to the hospital for disposition, without the assistance of a

funeral director, the delivering institution is solely responsible for completing the items on the

fetal death certificate and filing the certificate with the local registrar within five (5) days of the

fetal death. The facility will be responsible for all actions listed above in the section entitled

“Duties of the funeral director or other person accepting responsibility for disposition of the

fetus”.

If arrangements for disposition of the fetus are being made through a funeral director, the

principal responsibility of the delivering institution is to promptly provide health-related

information for the fetal death certificate, as needed, to the medical certifier to be able to

complete the cause of death information, so that the funeral director can file the certificate

with the local registrar within five (5) days of the fetal death.

Information the facility should provide includes, but is not limited to:

delivery date, sex, and place of delivery

information regarding the attendant and the signature of the medical certifier

(items 17a-18b)

health and medical information pertaining to the mother and fetus (items 34-53 on

the back of the fetal death certificate)

Confidentiality

Funeral directors or persons acting as such and certifiers of fetal death are assured that

extensive legal and administrative measures are used to protect individuals and

establishments from unauthorized disclosure of personal information.

The section entitled “For Medical and Health Use Only” on the back of the fetal death

certificate (items 34-53) is confidential and not considered open records for the purpose of

the open records law. That information may not be released or made public on subpoena or

otherwise, except that release may be made for statistical purpose only, so that no person,

patient, or facility is identified. [HSC §192.002]

Penalties

It is a Class A misdemeanor if a person knowingly reveals or induces another to reveal

confidential information from a death or fetal death certificate. It is a Class C misdemeanor if

a person refuses or fails to furnish correctly any information in the person’s possession

affecting a certificate. It is also a Class C misdemeanor if a person fails, neglects, or refuses

to fill out and file a death or fetal death certificate with the local registrar or deliver the

certificate upon request to the person with the duty to file it. It is a third degree felony to

falsely obtain, use, or alter another person’s certificate of death or fetal death with a fine of

up to $10,000 and 2-10 years in prison. [HSC §195]

Completing the Certificate

of Fetal Death Chapter 2

General Instructions

• Complete only one original certificate and file the original with the local registrar.

Reproductions or duplicates are not acceptable.

• Use the current form designated by the Texas Department of State Health Services,

Vital Statistics Section.

• All information except signatures should be typed. Manually printed certificates are

discouraged, but if it is not possible to type the information, print legibly using

permanent blue or black ink. [HSC 191.025(d)]

• All signatures must be written in permanent blue or black ink. Rubber stamp or other

facsimile signatures are not acceptable.

• Complete each item, following the specific instructions for that item. Do not leave

blanks unless specifically authorized.

• Do not use correction fluid or making alterations, erasures or strike-overs. Obvious

changes could affect the validity of a certificate and altered certificates may be

rejected by the local registrar or the State Vital Statistics Office.

• Avoid abbreviations, except those recommended in the specific item instructions.

• Verify with the informant the spelling of all names. Be especially careful with names

that sound the same but may have different spellings, for example, Wolf and Wolfe, or

Smith and Smyth.

• Refer problems not covered in these instructions to the State Vital Statistics Section

or to the local registrar.

Item-by-item Instructions

1. Name of Fetus (Optional – at the discretion of the parent(s))

Print or type the first, middle, and last names of the fetus including suffix. If the parent(s) do

not provide a first or middle name, leave these items blank; however, a last name must be

provided. If a middle name is not provided, do not enter NMI, NMN, etc.

 If the fetal remains are unidentified, enter the medical examiner case number.

NOTE: The parent(s) may give any name they desire as long as it will fit in the space

provided on the certificate. No numerical names, obscenities, or non-alphabetic characters

are permitted.

2. Date of Delivery (mm/dd/yyyy)

Enter the exact month, day and year that the fetus was delivered. You may use a number or

abbreviation to designate the month, e.g., 01/01/2007.

 If the fetus is found in this state, enter the word “found” and the date as the date of

delivery.

NOTE: Pay particular attention to the entry of the month, day, or year when the delivery

occurs around midnight or on December 31. Consider a delivery at midnight to have

occurred at the end of the day rather than at the beginning of the next day.

3. Time of Delivery

Enter the exact time (hour and minute) the fetus was delivered according to local time. If

daylight saving time was the official prevailing time when the delivery occurred, it should be

used to record the time of delivery. Be sure to indicate whether the time of delivery is A.M. or

P.M. One minute after 12 noon is entered as “12:01 pm”, and one minute after midnight is

entered as “12:01 am”.

Time can also be entered using 24- hour clock. Based on the recommendation the National

Center for Health Statistics received from the National Institute of Standards and Technology,

it is strongly recommended that the 24-hour clock with the range of 00:00-23:59 be used.

00:00 is considered the start of the new day.

In cases of plural deliveries, the exact time that the fetus was delivered should be recorded as

the hour and minute of delivery.

 If the fetus is found in this state, enter the word “found” and the time as the date of

delivery.

4. Sex

Enter Male or Female. Do not abbreviate or use other symbols.

If sex and name are inconsistent, verify both entries. If the sex cannot be determined after

verification with medical records, mother, or other sources, enter “Undetermined”.

NOTE: This item aids in identification of the fetus. It is also used to measure fetal and

perinatal mortality by sex. It helps identify differences in the impact of environmental and

biological factors between the sexes.

5. Place of Delivery - County

Enter the name of the county in which the delivery occurred.

 If the fetus is found in this state and the place of delivery is not known, the fetal death

should be registered in this state. The county where the fetus was found should be

considered the place of delivery.

6a. City or Town (If outside city limits, give precinct no.)/ 6b. Zip

Code:

Enter the name of the city and zip code in which the delivery occurred. If outside the city

limits, enter the justice of the peace precinct number. Spell out the word “Precinct”; do not

abbreviate.

 If the delivery occurred in a moving vehicle in the United States and the fetus was first

removed in Texas, complete a fetal death certificate showing Texas as the place of

delivery. The location of the facility of destination should be used in completing items

6a, 6b, 8a and 8b. “En Route” should be entered in field 8b, followed by the name of

the facility.

 For a delivery occurring at sea, Item 6a should show the place of event as “At Sea”,

and give the name of the vessel, along with the latitude and longitude where the

delivery occurred. It is important that the certificate contain some citation of the page

and volume number of the ship’s log. For a delivery occurring in international

airspace, complete a Certificate of Fetal Death, but enter the actual place of delivery

insofar as it can be determined.

 If a fetus is found in this state and the place of delivery is not known, the city where

the fetus was found should be considered the place of delivery.

Plurality—Delivery Order

7a. Number delivered:

Specify the delivery as single, twin, triplet, quadruplet, etc.

7b. Sequence:

Specify the order in which the infant being reported was delivered: first, second, etc.

 When a plural delivery occurs, prepare and file a separate certificate for each infant or

fetus. File certificates relating to the same plural delivery at the same time. However,

if holding the completed certificates while waiting for incomplete ones would result in

late filing, the completed certificates should be filed first.

NOTE: These items are related to other items on the certificate (for example, period of

gestation and birth weight) that have important health implications.

Place of Delivery

8a. Place of Delivery:

Check the place where the delivery occurred. Delivery in places of business or public places

are examples of “Other”. If “Other” is marked, enter the name of the other place.

If the delivery occurred in a moving vehicle, mark the box corresponding to the type of place

where the fetus was first removed from the vehicle.

 If a fetus is found in this state and the place of delivery is not known, the place where

the fetus was found should be considered the place of delivery.

 A birthing center located in and operated by a hospital is considered part of the

hospital and events should be reported as occurring in the hospital. Licensed birthing

centers include those facilities that are operated independently from hospitals

(autonomously). The “Clinic/Doctor’s Office” category includes other non-hospital

outpatient facilities where deliveries occasionally occur.

NOTE: This item identifies home deliveries, deliveries in licensed birthing centers, and

deliveries in non-hospital clinics or physician’s offices.

8b. Name of Hospital or Birthing Center (If not in hospital, give street address):

Enter the full name of the hospital in which the delivery occurred. It is very important to

always be consistent in entering the hospital name, there should be no variations. If the

delivery occurred in a vehicle en route to or upon arrival at a hospital, enter “En Route”,

followed by the name of the hospital.

 If the delivery occurred at home, enter the house number and street name of the

place where the delivery occurred. If the delivery occurred at some place other than

those described above, enter the number and street name of the location.

 If the delivery occurred in a vehicle that was not en route to a facility, enter as the

place of delivery the address where the fetus was first removed from the vehicle.

 If a fetus is found in this state, enter the place where the fetus was found should be

considered the place of delivery.

9. Mother’s Current Legal Name

First Name:

Enter the mother’s first name.

Middle Name:

Enter the mother’s middle name. If there is no middle name, leave this item blank, do not

enter NMI, NMN, etc.

Last Name:

Enter the mother’s current last name. This item will still need to be completed even if the

name is the same as in Item 11.

 If a fetus is found in this state and the mother’s legal name is not known, enter

“Unknown”.

10. Mother’s Date of Birth

Enter the exact month, day and year that the mother was born. Use numbers (mm/dd/yyyy).

If not known, enter “Unknown”; if exact day is not known enter the month and year only, e.g.

mm/yyyy.

11. Mother’s Name Prior to First Marriage

First Name:

Enter the mother’s first name. If the fetus was found, enter “Unknown”.

Middle Name:

Enter the mother’s middle name. If there is no middle name, leave this item blank, do not

enter NMI, NMN, etc.

Last Name:

Enter the mother’s maiden surname name. This would be the name that is listed on her birth

certificate. This item will still need to be completed even if the name is the same as in Item 9.

 If a fetus is found in this state and the mother’s name prior to first marriage is not

known, enter “Unknown”.

NOTE: The mother’s maiden surname is important because it remains constant throughout

her life, in contrast to other names, which may change because of marriage or divorce.

12. Birthplace

Enter the mother’s place of birth. If the mother was born in the United States, enter the name

of the state. If the mother was born in a foreign country or a U.S. territory, enter the name of

the country or territory.

 If the mother’s place of birth is not known, enter “Unknown”.

 If the mother was born in the United States or a U.S. Territory, but the exact state or

territory is unknown, enter “United States”.

 If the mother was born in a foreign country but the country is not known, enter

“Foreign”.

NOTE: This item provides information on recent immigrant groups, such as Asian and Pacific

Islanders, and is used for tracing family histories. It is also used to compare the childbearing

characteristics of women who were born in the United States with those of foreign-born

women.

13a-g Mother’s Residence

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.

Never enter a temporary residence, such as one used during a visit, business trip or

vacation. Residence for a short time at the home of a relative, friend, or home for unwed

mothers for the purpose of awaiting the birth of the child is considered temporary and should

not be entered here. However, place of residence during a tour of military duty or during

attendance at a college is not considered temporary and should be entered on the certificate

as the mother’s place of residence.

13a. Mother’s Residence—State:

If the mother is a U.S. resident, enter the U.S. state or territory where the mother lives. If the

state is not known, enter “Unknown”. Do not put “U.S.”, “United States”, etc.

If the mother is a Canadian resident, enter the name of the province or territory followed by

“Canada”. (exp. “British Columbia/Canada”)

If the mother is not a resident of the U.S., enter the name of the county of residence.

13b. County:

Enter the name of the county in which the mother lives. Leave this blank if the mother is not

a U.S. resident.

13c. City, Town, or Location:

Enter the city, town, or location in which the mother resides. Enter precinct number if no city

is available.

13d. Street Address or Rural Location:

Enter the number and street name of the mother’s residence, rural route number, or

description that will aid in identifying the location.

13e. Apt No. Enter the apartment or room number of the mother’s residence. Leave

this blank if not applicable.

13f. Zip Code

Enter the zip code for the mother’s residence. If not known, enter “Unknown”.

13g. Inside City Limits?

Mark "Yes" if the location entered in 10c is incorporated and if the mother's residence is

inside its boundaries; otherwise mark "No."

NOTE: Statistics on fetal deaths are tabulated by place of residence of the mother. This

makes it possible to compute fetal and perinatal death rates based on the population residing

in that area. These data are used in planning for and evaluating community services and

facilities, including maternal and child health programs. “Inside City Limits” is used to

properly assign residence to either the city or the remainder of the county.

14. Father’s Name

Enter the father’s name if one is provided; otherwise leave blank.

 No Acknowledgement of Paternity form (VS-159.1) is needed or required to list the

father. Completing this item does not reflect or establish paternity.

First Name:

Enter the father’s first name.

Middle Name:

Enter the father’s middle name. If there is no middle name leave this item blank, do not enter

NMI, NMN, etc.

Last Name:

Enter the father’s last name. Enter any suffixes following the last name.

 If a fetus is found in this state, leave the father’s name blank.

15. Father’s Date of Birth

Enter the exact month, day and year that the father was born. Use numbers or abbreviations,

e.g., MM-DD-YY. If not known, enter “Unknown”; if exact day is not known enter the month

and year only, e.g., mm/yyyy.

16. Birthplace (State, Territory, or Foreign County)

Enter the father’s place of birth. If the father was born in the United States, enter the name

of the state. If the father was born in a foreign country or a U.S. territory, enter the name

of the country or territory.

 If the father’s place of birth is not known, enter “Unknown”.

 If the father was born in the United States or a U.S. Territory, but the exact state or

territory is unknown, enter “United States”.

 If the father was born in a foreign country, but the country is unknown, enter “Foreign”.

NOTE: This item provides information on recent immigrant groups, such as Asian and Pacific

Islanders, and is used for tracing family histories.

17a-b. Attendant Information

17a. Attendant’s Name and Mailing Address

Print the full name and mailing address of the person in attendance at the delivery. Enter the

street and number, city or town, state and zip code.

 Emergency room physicians are considered to be the attending physician when a

fetus is delivered “En Route” to the facility if no other attendant can be identified or

located for signature.

 If a fetus is found in this state, enter the name of the certifier in item 18 as the

attendant.

17b. Type of Attendant Mark the appropriate box to identify the attendant’s title: M.D.

(Doctor of Medicine), D.O. (Doctor of Osteopathy), C.N.M. (Certified Nurse-Midwife),

Midwife, or Other. If “Other” is marked, enter the title of the attendant to the right of the

“Other (Specify)” box. Examples of “Other” are father, mother, grandmother, aunt,

paramedic, Emergency Medical Technician, policeman.

18a-b. Certifier Information

18a. Certifier Obtain the signature of the individual accepting the responsibility of certifying

that “to the best of my knowledge, the fetus was delivered at the time, date, and place as

shown and fetal death was due to the cause(s) as stated:” on the certificate. The certifier

may be either the attending physician at the time of delivery or the medical examiner/justice

of the peace. Signatures must be written in permanent blue or black ink. [HSC §191.025(d)]

 A midwife or certified nurse-widwife may be listed as an attendant on the fetal death

certificate; however they may not be listed as the certifier. Only a physician, medical

examiner, or justice of the peace may be listed as the certifier on the fetal death

certificate. In some cases the county judge may certify the delivery and when the

justice of the peace is not available to conduct an inquest. The county judge should

be notified only in cases that require an inquest. [CCP Art. 49.07(C)]

18b. Type of Certifier

Mark the appropriate box indicating whether the certifier is a physician, a medical examiner,

or a justice of the peace (acting as coroner).

19–24. Disposition

19. Method of Disposition

Check the box(es) corresponding to the method of disposition of the fetus. Removal from

state indicates the body was removed or shipped out of Texas for burial or other disposition.

Only one box should be marked.

If the fetus is to be used by a hospital, medical or mortuary school for scientific or

educational purposes, check “Donation” and specify the name and location of the institution

in items 22, 23, 24 and 25. “Donation” refers only to the entire fetus, not to individual organs.

 The remains are to be handled under the provisions of special or pathological wastes,

mark “Other” and enter “Hospital Disposition”.

20. Signature and License Number of Funeral Director or Person Acting as Such

The funeral service licensee or other person first assuming custody of the fetus and

charged with the responsibility for completing the fetal death certificate must sign in

permanent blue or black ink. Rubber stamps or facsimile signatures are not permitted.

[HSC §191.025(d)]

21. Unknown, Section, Block, Lot, Space:

Enter the appropriate information for Section, Block, Lot and Space (niche) to indicate the

location of the burial plot. If the cemetery has no designation of the actual location, mark

"Unknown". Do not leave this item incomplete.

 If the cemetery has some designation such as Section, but no Block, Lot, or Space,

enter the Section information and leave the other items blank.

 When designating the location of cremains that are placed in a columbarium, use the

spaces in this item that most closely match. The columbarium may not designate

specific locations in the same manner described on the death certificate, for example,

wing, section, row, lot, space, niche, etc.

 If the cremains are given to the family for disposition, mark "Unknown".

 If the fetus is to be used by a hospital, medical or mortuary school for scientific or

educational purposes, mark “Unknown”.

22. Place of Disposition (Name of Cemetery, Crematory, or Other Place): Enter the

name of the cemetery, crematory, or other place of disposition.

 If the body is cremated and the cremains are to be permanently entombed or buried,

enter the name of the crematory and the name of the cemetery, mausoleum,

columbarium, or location where the cremains will be permanently placed.

 If the cremains are given to the family for disposition, enter only the name of the

crematory.

 If the body is being shipped to a foreign country and the location (city or town) is

known, but no information is available regarding the name of the cemetery, enter only

the name of the city or town.

 If the fetus is to be used by a hospital, medical or mortuary school for scientific or

educational purposes, enter the name of that institution.

 If the disposition of the fetus is handled by the hospital under the provisions of special

or pathological wastes, enter the name of the institution as the place of disposition.

23. Location (City/Town, State)

Enter the name of the city, town, or village and the state (if out of state), or foreign country

where the place of disposition is located.

 If the body is to be used by a hospital, medical or mortuary school for scientific or

educational purposes, enter the location of that institution.

NOTE: This information indicates whether the fetus was properly disposed of as required by

law. It also serves to locate the fetal remains in case of exhumation, autopsy, or transfer.

24. Name of Funeral Facility [PROBLEM WITH FORMATTING]

Enter the name of the funeral facility or the name of the person acting as funeral director.

 If the body is to be used by a hospital, medical, or mortuary school for scientific or

educational purposes, enter the name of that institution.

 If the disposition of the fetus is handled by the hospital under the provisions of special

or pathological wastes, enter the name of that institution.

 If the person named in item 20 is not a funeral director, enter the name of that person.

25. Complete Address of Funeral Facility (Street and Number, City, State, Zip Code) Enter

the complete address of the funeral facility.

 If the body is to be used by a hospital, medical, or mortuary school for scientific or

educational purposes, enter the address of that institution.

 If the disposition of the fetus is handled by the hospital under the provisions of special

or pathological wastes, enter the address of that institution.

 If the person named in item 20 is not a funeral director, enter the address of that

person.

26a & 26b. Cause of Fetal Death

Physician/Medical Examiner

The cause-of-death section consists of two parts. The initiating cause/condition (26a) is for

reporting a single condition that most likely began the sequence of events resulting in the

death of the fetus. Other significant causes or conditions (26b) include all other conditions

contributing to death. These conditions may be conditions that are triggered by the initiating

cause (26a) or causes that are not among the sequence of events triggered by the initiating

cause (26a).

The cause-of-death information should be your best medical opinion. Report a specific

condition in the space most appropriate to the given situation. A condition can be listed as

“probable” even if it has not been definitively diagnosed. In reporting the causes of fetal

death, conditions in the fetus or patient, or of the placenta, cord, or membranes, should be

reported if they are believed to have adversely affected the fetus.

Cause of fetal death should include information provided by the pathologist if tissue analysis,

autopsy, or another type of postmortem exam was done. If microscopic exams for a fetal

death are still pending at the time the report is filed, the additional information should be

reported to the registrar as soon as it is available.

Cause-of-death is used for medical and epidemiological research on disease etiology and

evaluating the effectiveness of diagnostic and therapeutic techniques. It is a measure of

health status at local, state, national, and international levels.

Possible Solutions to Common Problems in Death Certification

Uncertainty:

Often several acceptable ways of writing a cause-of-death statement exist. Optimally, a

certifier will be able to provide a simple description of the initiating cause and other

contributing causes that is etiologically clear and to be confident that this is correct.

However, realistically, description of the process is sometimes difficult because the certifier

is not certain.

In this case, the certifier should think through the causes about which he/she is confident and

what possible etiologies could have resulted in these conditions. The certifier should select

the causes that are suspected to have been involved and use words such as “probable” or

“presumed” to indicate that the description provided is not completely certain. Causes of

death on the fetal death report should not include terms such as prematurity without

explaining the etiology because they have little value for public health or medical research.

Reporting a cause of fetal death as unknown should be a last resort.

When a number of conditions or multiple organ/system failure resulted in death, the

physician, medical examiner, or justice of the peace should choose a single condition which

most likely began the sequence of events resulting in the fetal death and list the other

conditions in 26b of the certification section. “Multiple system failure” could be included as an

“other significant cause or condition” but also specify the systems involved to ensure that the

detailed information is captured. Maternal conditions may have initiated or affected the

sequence that resulted in a fetal death. These maternal conditions should be reported in the

cause-of-death statement in addition to the fetal causes.

Avoid ambiguity:

Most certifiers will find themselves, at some point, in the circumstance in which they are

unable to provide a simple description of the process of death. In this situation, the certifier

should try to provide an initiating condition, qualify the causes about which he/she is

uncertain, and be able to explain the certification chosen.

27. Weight of Fetus (Grams Preferred, Specify Units)

Whenever possible, weigh and report the fetal weight in grams. Report weight in pounds

and ounces (lb/oz) only if weight in grams is not available. Do not convert from one measure

to the other. Please specify whether weight is in grams or lb/oz. Round fractional grams to

the nearest gram, and fractional ounces to the nearest ounce.

NOTE: This is the single most important characteristic associated with perinatal mortality. It

is also related to prenatal care, socioeconomic status, marital status, and other factors

surrounding the birth. Consequently, it is used with other information to plan for and evaluate

the effectiveness of health care.

28. Obstetric Estimate of Gestation at Delivery

Enter the obstetric estimate of the gestation of the fetus. If obstetric estimate of gestation is

not known, enter “Unknown”. Do not complete this item based on the date of delivery of the

fetus and the patient’s date of last menstrual period. It should be based on all parinatal

factors and assessments such as ultra sound, but not the neonatal exam.

29. Estimated Time of Fetal Death

Mark the most appropriate box.

30. Was An Autopsy Performed?

Mark “Yes” if a partial or complete autopsy was performed or is being performed at the time

of filing or the fetal death record. Mark “Planned” if an autopsy is not being performed at the

time of the filing of the fetal death record but one is going to be performed. Enter “No” if no

autopsy has been performed and no autopsy is planned.

NOTE: An autopsy is important in giving additional insight into the conditions that led to

death. This additional information is particularly important in arriving at the immediate and

underlying causes in violent deaths.

31. Was a Histological Placental Examination Performed?

Mark “Yes” if a Histological Placental Examination was performed or is being performed at

the time of filing. Mark “Planned” if a Histological Placental Examination is not being

performed at the time of the filing of the fetal death record but one is going to be performed.

Enter “No” if no Histological Placental Examination has been performed and no Histological

Placental Examination is planned.

32. Were Autopsy or Histological Placental Examination Results

Used in Determining the Cause of Death?

If items 30 and 31 are both “No”, this item does not have to be completed.

33 a-c. Registrar Information

The proper registrar is determined according to the place of death, not by place of disposition

or location of the funeral home.

33a. Registrar’s File Number

The local registrar will enter the appropriate file number. The number will consist of the

registrar’s unique two-digit number (registration location number) and the file number,

separated by dashes. The year may also be used if desired, and must be shown after the file

number and preceded by a dash. The local registrar shall consecutively number certificates

in separate series, beginning with the number “1" for the first certificate of each type in each

calendar year. For example, a registrar assigned the number “02” would enter the following

number for the first fetal death certificate completed in a year: “02-1”. The use of leading

zeros in the file number section is also permitted, e.g., “02-001.” If the registrar wishes to use

the year in the file number, it would read: “02-001-2007”.

33b. Date Received by Local Registrar

The local registrar will enter the date that the certificate is accepted and filed.

NOTE: This item documents whether the certificate was filed within the time period specified

by law.

33c. Signature of Local Registrar

The local registrar for the district in which the event occurred will sign the certificate when it

is accepted and filed. The signature may be either handwritten or a facsimile stamp, and

must be written or stamped with blue or black ink. If the certificate is signed by a deputy

registrar, the registrar’s name (typed, printed, or facsimile stamp) should be followed by the

deputy’s signature and title: Registrar’s name—by Deputy’s signature, Deputy Registrar.

Confidential Information for Medical and Public Health Use

Section 192.002 of the Texas Health and Safety Code states that the information and

records held under the section entitled “For Medical and Health Use Only” are confidential

and are not considered open records for the purpose of the open records law. That

information may not be released or made public on subpoena or otherwise, except that

release may be made for statistical purpose only, so that no person, patient, or facility is

identified.

A person commits an offense, a Class A misdemeanor, if the person knowingly discloses the

medical or health information, or knowingly induces or causes another to disclose

information.

34. Mother’s Education

mark the box that best describes the highest degree of level of school completed at the time

of delivery.

35. Is Mother of Hispanic Origin?

Mark the box that best describes whether the mother is Spanish/Hispanic/Latina. Mark the

“No” box if decedent is not Spanish/Hispanic/Latina. Please check only one box.

36. Mother’s Race

Mark the box(es) that best describes the race(s) of the mother as she considers herself to

be.

37a-e Pregnancy History

NOTE: These items are used to determine pregnancy frequencies and rates, which are

important in studying trends in childbearing and child spacing. They are also useful in

studying health problems associated with birth order; for example, first births to older women,

and determining the relationship of delivery order to infant and perinatal mortality.

Please give consideration to the mother’s right to privacy on issues related to previous

pregnancies.

37a-c Live Births

37a Now Living

Enter the number of children born alive to this mother who are still living. If the mother has

not had any live births, or if all live-born children have died, mark “None”. Children who have

been adopted or who have been given up for adoption may be reported or not reported

according to the mother’s wishes.

37b Now Dead

Enter the number of children born alive to this mother who are no longer living. If the mother

has not had any live births, or if all live-born children are currently living, mark “None”.

Children who have been adopted or who have been given up for adoption may be reported

or not reported according to the mother’s wishes.

37c Date of Last Live Birth (mm/yyyy)

Enter the date of the last live birth for this mother in month and year format. If the answers to

both items 37a and 37b are “None”, leave this item blank.

 If this certificate is for the second delivery of a twin set, enter the date of birth for the

first baby of the set, if it was born alive. Similarly for triplets or other multiple births,

enter the date of birth of the previous live birth of the set. If all previously born

members of a multiple set were born dead, enter the date of the mother’s last delivery

that resulted in live birth.

37d-e Other Pregnancies Outcomes

37d. Number

Enter the number of previous pregnancies that did not result in a live birth, regardless of the

length of gestation. Include all previous ectopic pregnancies, miscarriages, stillbirths, and

spontaneous or induced abortions.

 Do not include this fetal death. Mark “None” if this is the first pregnancy for this mother

or if all previous pregnancies have resulted in live births.

37e. Date Last Other Pregnancy Ended (mm/yyyy)

Enter the ending date of the last pregnancy that did not result in a live birth, in month and

year format (mm/yyyy). If the answer to 37d is “None”, leave this item blank. If the answer to

37d is other than “None”, but the date is not known, enter “Unknown”.

 If this certificate is for the second birth of a twin set and the first was born dead, enter

the date of delivery of that fetus. Similarly, for other multiple births, if any previous

member of the set was born dead, enter the date of delivery of that fetus.

38. Cigarette Smoking Before and During Pregnancy

For each time period, enter the number of cigarettes or the number of packs of cigarettes

smoked. If none, enter “0”.

39. Source of Prenatal Care

Mark the appropriate box(es) to indicate all sources of prenatal care during this pregnancy. If

the “Other” box is marked, enter the other source of prenatal care.

40. Mother’s Height.

If the mother’s height is not known, enter “Unknown”. Enter the patient’s height in feet and

inches. If the record indicates height in fractions such as 5 feet 6 ½ inches, truncate and

enter 5 feet, 6 inches.

41. Mother’s Prepregnancy Weight

If the mother’s prepregnancy weight is not known, enter “Unknown”. Record weight in whole

pounds only, do not include fractions.

42. Mother’s Weight at Delivery

If the mother’s delivery weight is not known, enter “Unknown”. Record weight in whole

pounds only, do not include fractions.

43a-c Prenatal Care

Enter the month, day, and year (mm/dd/yyyy) of the first prenatal visit, last prenatal visit, and

number of prenatal visits.

Complete all parts of the date that are available. 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 known, enter “Unknown”.

If there was no prenatal care you must check the box stating “No Prenatal Care”.

44. Date Last Normal Menses Began

Enter the date of the mother’s last normal menstrual period in mm/dd/yyyy format. If the day

is unknown, enter only the month and year. If the entire date is not known, enter “Unknown”.

NOTE: This item, in conjunction with the date of birth, is used to determine length of

gestation. A record with a plausible date that the Last Normal Menses Began provides a

cross-check with length of gestation based on ultrasound or other techniques.

45. Did Mother get WIC food for herself during this pregnancy?

This item is to be completed based on information obtained from the patient. Either the

“Yes” or “No” box must be marked.

46. Mother Married (At delivery, conception, or anytime

between?)

If the mother is currently married or married at the time of conception or any time between

conception and delivery, mark the “Yes” box.

If the mother is not currently married or was not married at the time of conception or any time

between conception and delivery, mark the “No” box.

47. Mother Transferred For Maternal Medical Or Fetal Indications

For Delivery?

Mark the “No” box if this is the first facility the mother was admitted to for delivery. Mark the

“Yes” box if the mother was transferred from one facility to another facility before the child

was delivered and enter the name of the facility from which the mother was transferred.

If the mother was transferred during labor from the care of a documented midwife, mark the

“Yes” box and type or print the word “Midwife”, followed by the midwife’s name.

If the mother was transferred more than once, enter the name of the last facility from which

she was transferred.

Transfer information is important in identifying high-risk deliveries and follow up on maternal

and infant deaths.

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

The mother may have more than one risk factor, check all boxes that apply.

If the mother had none of the risk factors, check the “None of the above” box.

If it is not known if the patient had any of the risk factors, enter “Unknown”.

49. Infections Present And/Or Treated During This Pregnancy

(Check all that apply)

If the prenatal care record is not available and the information is not available from other

medical records, write or type “Unknown”. More than one infection may be checked.

Gonorrhea – a positive test for Neisseria gonorrhoeae.

Syphilis (also called lues) B. a positive test for Treponema pallidum.

Chlamydia – a positive test for Chlamydia trachomatis.

Listeria (LM) – a diagnosis of or positive test for Listeria monocytogenes.

Group B Streptococcus (GBS) – a diagnosis of or positive test for Streptococcus

agalactiae or group B streptococcus.

Cytomeglovirus (CMV) – a diagnosis of or positive test for Cytomeglovirus.

Parvovirus (B19) – a diagnosis of or positive test for Parvovirus B19.

Toxoplasmosis (Toxo) – a diagnosis of or positive test for Toxoplasmosis gondii.

50a HIV Test Done Prematally

Mark the box that applies.

50b HIV Test Done at Delivery

Mark the box that applies.

51. Method Of Delivery

A response to each section is required.

If any of the information for an individual section is not known at this time, print or type

unknown in the space for the particular section.

The definitions below are available to assist in completing “method of delivery.”

Attempted forceps or vacuum: Obstetric forceps, ventouse or vacuum cup was

applied to the fetal head in an unsuccessful attempt to effect delivery of the head

through the vagina.

Cephalic presentation: Presenting part of the fetus listed as vertex, occiput anterior

(OA), occiput posterior (OP).

Breech presentation: Presenting part of the fetus listed as breech, complete breech,

frank breech, footling breech.

Other presentation: Any other presentation or presenting part not listed above.

Spontaneous delivery: Delivery of the entire fetus through the vagina by the natural

Forceps delivery: Delivery of the fetal head through the vagina by application of

obstetrical forceps to the fetal head.

Vacuum delivery: Delivery of the fetal head through the vagina by application of a

vacuum cup or ventouse to the fetal head.

Cesarean delivery: Extraction of the fetus, placenta and membranes through an

incision in thematernal abdominal and uterine walls.

Hysterotomy/Hysterectomy: Hysterotomy – the incision into the uterus extending

into the uterine cavity. May be performed vaginally or ransabdominally. Hysterectomy

– the surgical removal of the uterus. May be performed abdominally or vaginally.

52. Maternal Morbidity

Mark all boxes that apply.

Maternal transfusion: Includes infusion of whole blood or packed red blood cells

within the period specified.

Third or fourth degree perineal laceration: 3rd degree laceration extends

completely through the perineal skin, vaginal mucosa, perineal body and anal

sphincter. 4th degree laceration is all of the above with extension through the rectal

mucosa.

Ruptured Uterus: Tearing of the uterine wall.

Unplanned hysterectomy: Surgical removal of the uterus that was not planned prior

to admission for delivery. Includes an anticipated or possible but not definitively

planned procedure.

Admission to intensive care unit: Any admission, planned or unplanned, of the

patient to a facility/unit designated as providing intensive care.

Unplanned operating room procedure following delivery: Any transfer of the

patient back to a surgical area for an operative procedure that was not planned prior

to the admission for delivery. Excludes postpartum tubal ligations.

53. Congenital Anomalies Of The Newborn (Check all that apply)

Mark all boxes that apply to this fetus. For “Downs Syndrome” and Suspected Chromosomal

disorder”, if karyotype status is unknown leave both the “Karyotype confirmed” and

“Karyotype pending” boxes blank.

Anencephaly: Partial or complete absence of the brain and skull. Also called

anencephalus, acrania, or absent brain. Babies with craniorachischisis (anencephaly

with contiguous spine defect) should also be included in this category.

Meningomyelocele / Spina Bifida: Spina bifida refers to herniation of the meninges

and/or spinal cord tissue through a bony defect of spine closure. Meningomyelocele

refers to herniation of meninges and spinal cord tissue. Babies with meningocele

(herniation of meninges without spinal cord tissue) should also be included in the

category. Both open and closed (covered with skin) lesions should be included. Spina

bifida occulta (a midline bony spinal defect without protrusion of the spinal cord or

meninges) should not be included in this category.

Cyanotic congenital heart disease: Congenital heart defects which cause cyanosis.

Includes but is not limited to transposition of the great arteries (vessels), teratology of

Fallot, pulmonary or pulmonic valvular atresia, tricuspid atresia, truncus arteriosus,

total/partial anomalous pulmonary venous return with or without obstruction.

Congenital diaphragmatic hernia: Defect in the formation of the diaphragm allowing

herniation of abdominal organs into the thoracic cavity.

Omphalocele: A defect in the anterior abdominal wall, accompanied by herniation of

some abdominal organs through a widened umbilical ring into the umbilical stalk. The

defect is covered by a membrane, (different from gastroschisis, see below), although

this sac may rupture. Also called exomphalos. Umbilical hernia (completely covered

by skin) should not be included in this category.

Gastroschisis: An abnormality of the anterior abdominal wall, lateral to the umbilicus,

resulting in herniation of the abdominal contents directly into the amniotic cavity.

Differentiated from omphalocele by the location of the defect and absence of a

protective membrane.

Limb reduction defect: (excluding congenital amputation and dwarfing syndromes)

Complete or partial absence of a portion of an extremity secondary to failure to

develop.

Cleft Lip with or without Cleft Palate: Cleft lip with or without cleft palate refers to

incomplete closure of the lip. Cleft lip may be unilateral, bilateral or median; all should

be included in this category.

Cleft Palate alone: Cleft palate refers to incomplete fusion of the palatal shelves.

This may be limited to the soft palate or may also extend into the hard palate. Cleft

palate in the presence of cleft lip should be included in the “Cleft Lip with or without

cleft

Palate” category, rather than here.

Down Syndrome: Trisomy 21.

Suspected chromosomal disorder: Includes any constellation of congenital

malformations resulting from or compatible with known syndromes caused by

detectable defects in chromosome structure.

Hypospadias: Incomplete closure of the male urethra resulting in the urethral meatus

opening on the ventral surface of the penis. Includes first degree – on the glans

ventral to the tip, second degree – in the coronal sulcus, and third degree – on the

penile shaft.

Permits And Authorizations Associated

With Fetal Death Registration Chapter 3

Report Of Death Form (Form VS-115)

[25 TAC §181.2(a)]

The funeral director or person acting as such, who first assumes custody of a fetus, shall

within 24 hours either mail or otherwise transmit a Report of Death to the local registrar of

the district in which the death occurred or the body or fetus was found. A copy of the Report

of Death form shall serve as authority to transport or bury the fetus within this state (serves

as a Burial-Transit Permit).

Instructions For Completing The Report Of Death Form For A Fetal Death:

1) Type or print legibly in permanent blue or black ink the full name of the fetus. If the

parents do not provide a first name, leave the first name blank. However, a last name

MUST be entered.

2) Enter the date of delivery in the block marked “date of death”.

3) In the block marked “place of death”, enter the county and city, or precinct number, in

which the delivery occurred.

4) Enter the sex and race of the fetus.

5) In the block marked “age in years at the last birthday” type or print “fetus”. 6) Enter the

date the Report of Death form is mailed to the local registrar.

7) Provide the typed or printed name and signature of the funeral director.

8) Enter the funeral director’s license number and full address.

Burial-Transit Permit (form VS-116)

[HSC, §193.008, 25 TAC §181.2, §181.3]

A Burial-Transit Permit is required to ship or transport a fetus out of this state, or to transport

a fetus by common carrier within this state. A Burial-Transit Permit is also required for

cremation.

If an inquest is being conducted by the medical examiner or justice of the peace,

authorization for cremation from the medical examiner or justice of the peace is required in

addition to the Burial-Transit Permit.

A Burial-Transit Permit is not necessary if transporting a fetus within the state by means

other than common carrier. A copy of the Report of Death form is sufficient.

The Burial-Transit Permit is issued by the local registrar, the registrar’s deputy, or some

other authorized officer of the district in which the death occurred, or the district in which the

body or fetus was found. The local registrar shall not issue a Burial-Transit Permit until the

Certificate of Fetal Death, completed in so far as possible, has been filed.

The State Vital Statistics Office interpretation of “completed in so far as possible” means all

of the information relating to the fetus, such as the name, date of delivery, place of delivery,

and funeral director’s information is complete. In a few instances the physician may not

have certified the cause of fetal death before removal from the district is desired.

It is the responsibility of the funeral director, or person acting as such, filing the partially

completed Certificate of Fetal Death, and obtaining the Burial-Transit Permit, to assure that

the fully completed Certificate of Fetal Death is filed with the local registrar as soon as

possible. If an incomplete certificate is used to obtain the Burial-Transit Permit, the registrar

may wish to validate that the fetus is no longer needed by the certifier of cause-of-death

before issuing the permit, to assure that a completed fetal death certificate will be received.

A properly issued Burial-Transit Permit issued under the law and rules of a place outside this

state, in which the fetal death occurred, authorizes the transportation of the fetus in this

state. A cemetery or crematory shall accept the permit as authorization for burial, cremation,

or other disposal of the fetus in this state.

It is unlawful for any sexton or other person in charge of a burial place to permit burial or

other disposition of a fetus before a Burial-Transit Permit or a Report of Death is deposited

with him. The sexton, or person in charge, may accept the permit of any state, country, or

the District of Columbia.

There is no fee authorized for the issuance of a Burial-Transit Permit. Please contact the

local registrar for information on how to obtain a Burial-Transit Permit when the local

registrar’s office is closed.

Authorization For Cremation

[CCP, Art. 49.09, 49.25(10, 10a), 25 TAC §181.2]

The Report of Death does not take the place of the Burial-Transit Permit for cremation. A

Burial-Transit Permit must be obtained for cremation.

A body may not be cremated within 48 hours after the time of death as indicated on the

death certificate, unless the death certificate indicates the death was due to Asiatic cholera,

bubonic plague, typhus fever or small pox, or unless the time requirement is waived in

writing by the medical examiner or coroner.

If an inquest is being conducted by the medical examiner or coroner, authorization for

cremation from the medical examiner or coroner is required in addition to a Burial-Transit

permit. A fetus may not be cremated until the medical examiner or coroner has signed a

certificate stating that an autopsy was performed, or that no autopsy was necessary.

If no inquest is being held, a certificate signed by the medical examiner or coroner is not

necessary prior to cremation and a Burial-Transit Permit will suffice.

Disinterment Permit (form VS-2219)

[HSC, §694.001, §711.004, 25 TAC §181.6]

The Disinterment Permit issued by the State Registrar shall serve as the authority to disinter,

transport and re-inter a fetus within this state. If the fetus is to be removed from this state,

transported by common carrier within this state, or cremated, a Burial-Transit Permit must

also be obtained.

A Disinterment Permit shall not be required if a fetus is to be disinterred and reinterred in the

same cemetery.

The Application for Disinterment Permit (Form VS-271) must be signed by a funeral director

or embalmer licensed by the Texas Funeral Commission making the application for the

permit. The sole responsibility for obtaining the consent of the cemetery, the owner of the

plot, and the decedent’s next-of-kin rests with the funeral director or embalmer making the

application for a disinterment permit. The application, consent forms and required fee must

be sent to the State Vital Statistics Office.

The State Registrar shall issue the Disinterment Permit in four parts. The funeral director to

whom the permit is issued shall retain one copy, one copy is to be filed by the sexton of the

cemetery in which the reinterment is to be made, one copy shall be filed by the local registrar

with the local registrar’s copy of the Certificate of Fetal Death, and one copy will be filed by

the State Registrar with the original Certificate of Fetal Death.

Instructions For Completing The Application For The Disinterment Permit For A Fetal

Death:

Please type or print, except where signatures are required. Names may be typed beneath

the signature for clarity.

1) Enter the full name of the fetus as it appears on the Certificate of Fetal Death.

2) On the line marked “date of death”, enter the date of delivery. This information is vital

in locating and identifying the fetal death certificate.

3) On the line marked “place of death”, enter the city, county and state in which the

delivery occurred.

4) Enter the place of interment. These items must be completed with the full name of

the cemetery, plot number (section, block, lot, and space or niche), city, county, and

state in which the fetus is buried. The state should always be Texas as we cannot

issue a Disinterment Permit for a burial in another state.

5) Enter the place the fetus is to be reinterred (items a-d). These items must be

completed with the full name of the cemetery, plot number (section, block, lot, and

space or niche), city, county, and state where the body will be reinterred.

6) Enter the full name of the funeral director, license number, and the full name, address

and telephone number of the funeral home.

7) Provide the date and signature of the funeral director submitting the application.

Instructions For Completing The Disinterment Consent Forms For A Fetal Death:

Please type or print, except where signatures are required. Names may be typed beneath

the signature for clarity.

1) The first portion of the form entitled “Cemetery consent form” must be

completed by the cemetery owner or keeper.

a) Enter the full name of the fetus as it appears on the Certificate of Fetal Death.

b) Enter the plot and block number where the fetus is buried.

c) Enter the full name of the plot owner(s).

d) The signature line should be completed by the cemetery owner or keeper.

e) Enter the date the form was signed.

f) Enter the title of the person signing for the cemetery.

g) Enter the full name of the cemetery where the fetus is buried.

2) The center portion of the form entitled “Plot owner consent form” should be

completed by the owner of the plot where the fetus is buried.

a) Enter the plot and block number where the fetus is buried.

b) Enter the complete name of the cemetery where the fetus is buried.

c) Enter the full name of the fetus as it appears on the Certificate of Fetal Death.

d) The signature line should be completed by the person owning the plot.

e) Enter the date signed, and address and telephone number of the plot owner.

3) The third portion of the form entitled “Next-of-kin consent form” must be

completed by the next of kin.

a) Enter the relationship of the person signing to that of the fetus.

b) Enter the full name of the fetus as it appears on the Certificate of Fetal Death.

c) Enter the full name of the cemetery where the fetus is to be reinterred.

d) The signature line should be completed by the next of kin.

e) Enter the date signed.