TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER e: VITAL RECORDS
PART 500 ILLINOIS VITAL RECORDS CODE
SECTION 500.APPENDIX F DEATH RECORDS



Section 500.APPENDIX F   Death Records

 

Section 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

MULTIPLE BIRTHS
Enter State File Number for Mate(s)
LIVE BIRTH(S) 

FETAL DEATH(S)
(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)

 

 

 

21a.    None

21b.    None

21d.     None

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.

 

 

Printed by the Authority of the State of Illinois
Illinois Department of Public Health – Division of Vital Records
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

 

 

 

 

Hydramnios/Oligohydramnios.....................

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

 

 

Other (specify) ________________________

17

 

 

Seizures during labor............................................

07

Other urogenital anomalies

 

 

 

 

 

 

 

 

 

 

 

Precipitous labor (<3hours)..................................

08

 

 

(Specify) __________________

14

 

 

 

 

30b.  OTHER RISK FACTORS FOR THIS

 

 

 

 

Prolonged labor (>20 hours)...................................................

09

Cleft lip/palate...........................................

15

 

 

PREGNANCY (Complete all items)

 

 

 

 

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

 

 

Weight gain during pregnancy _____ lbs.

 

 

 

 

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)