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Get MI DCH-0569-SB 2020-2024

APPLICATION FOR A CERTIFIED COPY MICHIGAN CERTIFICATE OF STILLBIRTH Michigan Department of Health and Human Services The Michigan Vital Records Office issues certificates of stillbirths that occurred in Michigan with information filed with the state after June 1 2003. 2894 b and 445. 65. Applicant s Signature Date Current valid Government-issued photo ID required see back for Acceptable Documents PART 3 - PURPOSE FOR REQUESTING THE RECORD PART 4 - ELIGIBILITY - Are you eligible to request this Certificate of Stillbirth Michigan law limits who can receive a certified copy of a Michigan Certificate of Stillbirth. Make checks and money orders payable to State of Michigan. PROCESSING TIMES FOR STILLBIRTH The Certificate of Stillbirth will be available within ten 10 days after the required identifying report is received by the state from the hospital or attending physician. MAIL APPLICATION TO REGULAR MAIL TO Vital Records Requests PO Box 30721 RUSH MAIL TO 517-335-8666 The Michigan Department of Health and Human Services MDHHS does not discriminate against any individual or group because of race religion age national origin color height weight marital status genetic information sex sexual orientation gender identity or expression political beliefs or disability. PART 1 - APPLICANT S INFORMATION Applicant s Name State Driver s License or Identification Mailing Address City Daytime Phone w/area code - Required State Zip Other Phone w/area code PART 2 - CERTIFICATION OF INFORMATION PROVIDED By signing this application I understand that I am agreeing to pay for a search of the State of Michigan Vital Records. This does not guarantee that a record will be found. Falsifying an application for a vital record and/or assuming the identity of another person is subject to criminal penalties MCL 333. Parent named on certificate Court of competent jurisdiction court order attached PART 5 - INFORMATION NEEDED TO LOCATE THE CERTIFICATE BEING REQUESTED Child s Full Name first middle last Date of Delivery mm/dd/yyyy Hospital County Mother s Name Mother s Date of Birth PART 6 - FEES - Check Payable to State of Michigan Base Fee Includes One Year Search Age 64 and Under 34. 00 Additional Copies Each x 16. 00 Additional Years Search yrs when exact year unknown Years you want searched Expedited RUSH Service additional 12. 00 Payment to State of Michigan TOTAL Note Applications sent to the Vital Records post office box with an overnight delivery are not received in Vital Records for three days. For Accounting Use Only APPLYING IN PERSON LOCATION South Grand Building 1st Floor 333 S Grand Avenue Lansing MI 48933 corner of Grand Kalamazoo LOBBY HOURS 8 00 am - 5 00 pm M-F except for recognized state holidays. DIRECTIONS Visit our website at www. michigan*gov/vitalrecords or call 517-335-8666. SAME DAY SERVICE Orders at our counter must be placed by 3 00 pm to receive same-day service. Additional rush fee of 12. 00 is required for sameday service and you must allow up to a 2 hour waiting period for the order to be processed* Genealogy requests may take longer.

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