Iowa Department of Public Health, Bureau of Health Statistics | Revised July 15, 2017 Page 2
ABLE OF
ONTENTS
Introduction .................................................................................................................................................. 4
Legal Responsibilities ................................................................................................................................... 7
Assuming Custody ...................................................................................................................................... 10
Fetus Information ....................................................................................................................................... 11
Name of Fetus ........................................................................................................................................... 12
Sex of Fetus .............................................................................................................................................. 13
Delivery ........................................................................................................................................................ 13
Date of Delivery ........................................................................................................................................ 14
Time of Delivery ....................................................................................................................................... 14
Title ........................................................................................................................................................... 15
Place of Delivery....................................................................................................................................... 16
Facility Name ............................................................................................................................................ 17
City, Town or Location ............................................................................................................................. 17
Parent 1 ........................................................................................................................................................ 17
Mother’s Current Legal Name .................................................................................................................. 18
Mother’s Date of Birth .............................................................................................................................. 19
Mother’s Name Prior to any Marriage ...................................................................................................... 19
Mother’s Birthplace .................................................................................................................................. 20
Mother’s Residence .................................................................................................................................. 21
Residence – State ...................................................................................................................................... 22
Residence – County .................................................................................................................................. 23
Residence – City or Town ......................................................................................................................... 23
Residence – Street, Number & Zip Code .................................................................................................. 24
Residence – Inside City Limits ................................................................................................................. 24
Parent 2 ........................................................................................................................................................
25
Parent 2 Current Legal Name ................................................................................................................... 26
Parent 2 Date of Birth ............................................................................................................................... 27
Parent 2 Name Prior to any Marriage ....................................................................................................... 27
Parent 2 Birthplace .................................................................................................................................... 28
Disposition ................................................................................................................................................... 29
Method of Disposition .............................................................................................................................. 30
Place of Disposition .................................................................................................................................. 32
Location of Disposition............................................................................................................................. 32
Person Responsible for Disposition .......................................................................................................... 33
Full Address .............................................................................................................................................. 33
Signature of Funeral Director or Person Responsible for Disposition ...................................................... 34
Funeral Director/License Number ............................................................................................................ 34
Cause/Conditions Contributing to Fetal Death ....................................................................................... 35
Initiating Cause or Condition .................................................................................................................... 38
Other Significant Causes or Conditions .................................................................................................... 39
Weight of Fetus ......................................................................................................................................... 40
Obstetric Estimate of Gestation at Delivery ............................................................................................. 40
Estimated Time of Fetal Death ................................................................................................................. 41