Illinois Administrative Code (Last Updated: March 27, 2024) |
TITLE77. PUBLIC HEALTH |
PART500. ILLINOIS VITAL RECORDS CODE |
Section500.APPENDIX F. Death Records |
§500.ILLUSTRATION A. Certificate of Fetal Death
-
Type or Print in
PERMANENT INK
See Hospital and
REGISTRATION DISTRICT NO
REGISTERED NUMBER
STATE OF ILLINOIS
STATE FILE
NUMBER
Funeral Directors
Handbooks for
CERTIFICATE OF FETAL DEATH
INSTRUCTIONS
FETUS-NAME
FIRST
MIDDLE
LAST
DATE OF DELIVERY (MONTH DAY YEAR)
HOUR
1.
2a.
2b.
M
FETUS
SEX
COUTY OF DELIVERY
CITY, TOWN, TWP OR ROAD DISTRICT NO
HOSPITAL –NAME (IF NOT HOSPITAL GIVE STREET AND NUMBER)
3.
4a.
4b.
4c.
MOTHER-MAIDEN NAME
FIRST
MIDDLE
LAST
DATE OF BIRTH (MONTH DAY YEAR)
BIRTHPLACE
(STATE OR FOREIGN COUNTRY)
5c.
MOTHER
5a.
5b.
RESIDENCE - STREET AND NUMBER OR RFD
CITY, TOWN, TWP OR ROAD DISTRICT NO
INSIDE CITY
(YES NO)
COUNTY
STATE
ZIP CODE
6a.
6b.
6c.
6d.
6e.
6f.
FATHER
FATHER - NAME
FIRST
MIDDLE
LAST
DATE OF BIRTH (MONTH DAY YEAR)
BIRTHPALCE
(STATE OR FOREIGN COUNTRY)
7a.
7b.
7c.
INFORMANT'S SIGNATURE
RELATIONSHIP
MAILING ADDRESS (STREET AND NO. OR R.F.D. CITY OR TOWN, STATE AND ZIP)
8a.►
8b.
8c.
9. PART 1 FETAL DEATH WAS CAUSED BY
(ENTER ONLY ONE CAUSE PER LINE FOR (a), (b) AND (c))
SPECIFY FETAL OR MATERNAL
FETAL OR MATERNAL
CONDITION DIRECTLY
CAUSING FETAL DEATH
IMMEDIATE CAUSE
{
(a)
DUE TO OR AS A CONSEQUENCE OF
FETAL AND OR MATER-
NAL CONDITIONS, IF ANY,
GIVING RISE TO THE
IMMEDIATE CAUSE (a),
STATING THE UNDERLY-
ING CAUSE LAST
{
CAUSE
(b)
DUE TO OR AS A CONSEQUENCE OF
(c)
PART II OTHER SIGNIFICANT CONDITIONS OF FETUS OR MOTHER CONTRIBUTING TO FETAL DEATH BUT NOT RESULTING IN THE UNDERLYING CAUSE GIVEN IN PART I
FETUS DIED BEFORE LABOR, DURING LABOR OR DELIVERY UNKNOWN (SPECIFY)
AUTOPSY
(YES NO)
WERE AUTOPSY FINDINGS AVAILALE PRIOR TO COMPLETION OF CAUSE OF DEATH? (YES NO)
10.
11a.
11b.
I CERTIFY THAT THIS FETUS WAS BORN DEAD AT THE PLACE AND TIME ON THE DATE STATED ABOVE
DATE SIGNED (MONTH DAY YEAR)
ATTENDANT – M.D., D.O., MIDWIFE, OTHER (SPECIFY)
SIGNATURE
CERTIFIER
12a. ►
12b.
12c.
CERTIFIER'S COMPLETE MAILING ADDRESS (STREET AND NO OR R.F.D., CITY OR TOWN, STATE, ZIP)
ILLINOIS LICENSE NUMBER
12d.
13.
BURIAL, CREMATION, OR REMOVAL
CEMETERY OR CREMATORY – NAME
LOCATION (CITY OR TOWN, STATE)
DATE (MONTH DAY YEAR)
(SPECIFY)
14a.
14b.
14c.
14d.
FUNERAL HOME
NAME
STREET AND NUMBER OR R.F.D.
CITY OR TOWN
STATE
ZIP
15a.
DISPOSITION
FUNERAL DIRECTOR'S SIGNATURE
FUNERAL DIRECTOR'S ILLINOIS LICENSE NUMBER
15b.
15c.
LOCAL REGISTRARS SIGNATURE
DATE FILED BY LOCAL REGISTAR (MONTH, DAY, YEAR)
16a. ►
16b.
Section 500.APPENDIX F Death Records
Section 500.ILLUSTRATION A Certificate of Fetal Death (Continued)
VR-110-(11/89)
INFORMATION FOR HEALTH AND STATISTICAL USE ONLY
(BASED ON 1989 U.S. STANDARD CERTIFICATE)
OF HISPANIC ORGIN?
RACE-American Indian,
19. EDUCATION
20. OCCUPATION AND BUSINESS/INDUSTRY
(Specify below No or Yes-If Yes
specify Cuban, Mexican, Puerto Rican, etc.)
Black, White, etc.
(Specify only highest grade completed)
(Worked during last year)
(Specify below)
Elementary/Secondary (0-12)
College (1-4 or 5+)
Occupation
Business/Industry
17.
18.
No
Yes
MOTHER
17a.
Specify:
18a.
19a.
20a.
20b.
No
Yes
FATHER
17b.
Specify:
18b.
19b.
20c.
20d.
21. PREGNANCY HISTORY
(Complete each section)
MOTHER MARRIED? at delivery, conception or at
DATE LAST NORMAL MENSES BEGAN
any time between (Yes or No)
(Month, Day, Year)
22.
23.
LIVE BIRTHS
OTHER TERMINATIONS
(Spontaneous and induced at
any time after conception)
MONTH OF PREGNANCY PRENATAL CARE BEGAN
PRENATAL VISTS
First, Second, Third, Etc. (Specify)
Total Number (if none so state)
24.
25.
NOW LIVING
NOW DEAD
(Do Not Include This Fetus)
WEIGHT OF FETUS
CLINICAL ESTIMATE OF GESTATION
Number
Number
Number
(Specify Units)
26.
27.
Weeks
DATE OF LAST LIVE BIRTH
DATE OF LAST OTHER TERMINATION
PLURALITY
IF NOT SINGLE BIRTH - Born
(Month, Year)
(Month, Year)
Single, Twin, Triplet, etc. (Specify)
First, Second, Third, etc. (Specify)
21c.
21e.
28a.
28b.
DATE OF MOTHER'S BLOOD TEST FOR SYPHILIS (Month Day Year)
LABORATORY DOING THE SEROLOGY
29a.
29b.
30a.
MEDICAL RISK FACTORS FOR THIS PREGNANCY
(Check all that apply)
32.
OBSTETRIC PROCEDURES
(Check all that apply)
34.
CONGENITAL ANOMALIES OF
FETUS (Check all that apply)
Anemia (Hct.<30/Hgb. <10).............................................
01
Amniocentesis......................................................
01
Anencephalus............................................
01
Cardiac disease.............................................
02
Electronic fetal monitoring......................
02
Spina bifida/Meningocele.............
02
Acute or chronic lung disease.........................................
03
Induction of labor...................................................
03
Hydrocephalus..........................................
03
Diabetes.......................................................................
04
Stimulation of labor................................
04
Microcephalus.............................
04
Genital herpes...............................................................
05
Tocolysis..............................................................
05
Other central nervous system anomalies
06
Ultrasound............................................
06
(Specify) ___________________________
05
Hemoglobinopathy...................................................
07
None.....................................................................
00
Heart malformations.....................
06
Hypertension, chronic..................................
08
Other (specify)_____________________
07
Other circulatory/respiratory anomalies
Hypertension, pregnancy associated..............................
09
(Specify) ___________________________
07
Eclampsia......................................................
10
33. COMPLICATIONS OF LABOR
Rectal atresia/stenosis.................
08
Incompetent cervix........................................................
11
AND/OR DELIVERY (Check all that apply)
Tracheo-esophageal fistula/
Previous infant 4000 + grams..........................
12
Febrile (>100°F. or 38°C.)......................................
01
Esophageal atresia....................................
09
Previous preterm or small-for-gestational-age infant.........
13
Meconium, moderate, heavy..................................
02
Omphalocele/Gastroschisis..........
10
Renal disease.................................................
14
Premature rupture of membrane (>12 hours)
03
Other gastrointestinal anomalies
Rh sensitization............................................................
15
Abruptio placenta..................................
04
(Specify) ___________________________
11
Uterine bleeding.............................................
16
Placenta previa.....................................................
05
Malformed genitalia......................
12
None.............................................................................
00
Other excessive bleeding.......................................
06
Renal agenesis..........................................
13
17
Seizures during labor.............................................
07
Other urogenital anomalies
Precipitous labor (<3hours)....................................
08
(Specify) __________________
14
Prolonged labor (>20 hours)....................................................
09
Cleft lip/palate............................................
15
Dysfunctional labor................................................
10
Polydactyly/Syndactyly/Adactyly...
16
Tobacco use during pregnancy........................
Yes
No
Breech/Malpresentation.........................................
11
Club foot....................................................
17
Average number of cigarettes per day ___
Cephalopelvic disproportion...................
12
Diaphragmatic hernia...................
18
Alcohol use during pregnancy..........................
Yes
No
Cord prolapse.......................................................
13
Other musculoskeletal/integumental anomalies
Average number drinks per week _____
Anesthetic complications.......................
14
(Specify) ___________________________
19
Fetal Distress........................................................
15
Down's syndrome........................
20
None.....................................................
00
Other chromosomal anomalies
31. METHOD OF DELIVERY (Check all that apply)
Other (specify)......................................................
16
(Specify) ___________________________
21
SOCIAL SECURITY NUMBER
None............................................
00
Vaginal.........................................................................
01
MOTHER
Other (specify) _____________________
22
Vaginal birth after previous C-section...............
02
35.
Primary C-section.........................................................
03
SOCIAL SECURITY NUMBER
Repeat C-section ...........................................
04
FATHER
Forceps........................................................................
05
36.
Vacuum..........................................................
06
Hysterotomy/Hysterectomy............................................
07
(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)