For a Birth Resulting in Stillbirth, Records and Certificates
Print this page and mail or fax it with your completed application(s).
|Print your name as it appears on your application:|
|How many||Item||Fee for each||Total|
|First certificate for each record ordered||
|Additional certificates for same record||
|Delayed Filing Fee: Required if there has been more than one year since the fetal death.||
|Optional - Federal Express Mail Service is $16 for most deliveries. Higher rates apply to Saturday or international service and to deliveries to Alaska and Hawaii.||
(per order only)
Total amount included:
|Credit Card Information (use only Master Card, VISA, or Discover Card)|
Make your check or money order payable to the Minnesota Department of Health. Checks returned for nonpayment will be charged a $30 fee according to Minnesota Statutes, section 604.113, subdivision 2, and civil penalties may be imposed for nonpayment.
Mail the completed application form, any required documentation as indicated on the application, this fee worksheet, and payment to:
Minnesota Department of Health
Attention: Office of the State Registrar
P.O. Box 64499
St. Paul, Minnesota 55164-0499
Fax the completed form, birth resulting in stillbirth record and certificate fee worksheet, credit card (Master Card, VISA, and Discover Card) number and expiration date to 651-201-5750.
If you have questions, please e-mail email@example.com