Part III. Data Required on Vital Statistics Certificates
12VAC5-550-100. Birth certificate items.
A. Certificate of Live Birth, Commonwealth of Virginia, for registrations at time of birth, shall contain the following items: child's full name; place of birth; usual residence of mother; sex of child; single or plural birth, and birth order of plural birth; date of birth; full name of father (except when mother is not married to the father); age of father (except when mother is not married to the father); birthplace of father (except when mother is not married to the father); full maiden name of mother; age of mother; birthplace of mother; certification of parent (if available); certification of attendant at the birth, including title, address and date signed; date the certificate was received by the registrar; registrar's signature; registration area and certificate numbers; state birth number; and supplemental confidential data to consist of the following items: medical record and social security numbers of the mother; medical record number of the child; hispanic origin, if any, and race of mother; education of mother; mother transferred prior to delivery; hispanic origin, if any, and race of father (except when mother is not married to the father); social security numbers of the father; education of father (except when mother is not married to the father); pregnancy history of mother, including date of last live birth and date of last other termination of pregnancy; date of last normal menses and physician's or midwife's estimate of gestation; month of pregnancy prenatal care began; source of prenatal care; number of prenatal visits; birthweight of child in grams; mother married to father of child; Apgar score of child at one minute and five minutes; obstetric procedures and method of delivery; newborn conditions and congenital malformations or anomalies of child, if any; infant transferred; medical history for this pregnancy; other history for this pregnancy; events of labor and delivery, and an optional item for the parent to request the State Registrar to report the birth to the Social Security Administration for account number issuance.
B. Delayed Certificate of Birth, Commonwealth of Virginia, for delayed registrations of birth, shall contain the following items: full name at time of birth; sex; place of birth; date of birth; name of father (except when mother was not married to father at the time of birth or during the 10 months next preceding the birth); race of father (except when mother was not married to the father); birthplace of father (except when mother was not married to the father); full maiden name of mother; race of mother; birthplace of mother; certification and signature of applicant; address of applicant; relationship of applicant to registrant; statement and signature of notary public (or other official authorized to administer oaths); description of documentary evidence submitted; certification and authorized signature of the State Registrar; date certificate filed by the State Registrar; and number of certificate.
C. Certificate of Live Home Birth, Commonwealth of Virginia, is required to be registered within 30 days after time of birth and shall be registered with the local health department in which the birth occurred. The local registrar or the deputy registrar shall forward such registration of Live Home Birth filed within 30 days to the State Registrar. The Certificate of Live Home Birth, Commonwealth of Virginia, for registrations at time of birth, shall contain the following items: child's full name; place of birth; usual residence of mother; sex of child; single or plural birth and birth order of plural birth; date of birth; full name of father (except when the mother is not married to the father); age of father (except when the mother is not married to the father); birthplace of father (except when the mother is not married to the father); full maiden name of mother; age of mother; birthplace of mother; certification of parent (if available); certification of attendant at birth, including title, address, and date signed; date the certificate was received by the registrar; registrar's signature; registration area and certificate numbers; state birth number; and supplemental confidential data to consist of the following items: medical record and social security numbers of the mother; hispanic origin, if any, and race of mother; education of mother; mother transferred prior to delivery; hispanic origin, if any, and race of father (except when mother is not married to the father); social security number of the father; education of father (except when mother is not married to the father); pregnancy history of the mother, including date of last live birth and date of last other termination of pregnancy; date of last normal menses and physician's or midwife's estimate of gestation; month of pregnancy prenatal care began; source of prenatal care; number of prenatal visits; birth weight of child in grams; mother married to father of child; Apgar score of child at one minute and five minutes; obstetric procedures and method of delivery; newborn conditions and congenital malformations or anomalies of child, if any, infant transferred; medical history of this pregnancy; other history of this pregnancy; events of labor and delivery and an optional item for the parent to request the State Registrar to report the birth to the Social Security Administration for account number issuance. If the Certificate of Live Home Birth is not filed at the time of birth or within 30 days, supporting documents to establish a registration may be required and shall be as follows:
1. Evidence of pregnancy, such as but not limited to:
a. Prenatal record;
b. A statement from a physician or other health care provider qualified to determine pregnancy;
c. A home visit by a public health nurse or other health care provider; or
d. Other evidence acceptable to the State Registrar.
2. Evidence that the infant was born alive, such as but not limited to:
a. A statement from the physician or other health care provider who saw or examined the infant;
b. An observation of the infant during a home visit by a public health nurse; or
c. Other evidence acceptable to the State Registrar.
3. Evidence of the mother's presence in the Commonwealth of Virginia on the date of the birth, such as but not limited to:
a. If the birth occurred in the mother's residence;
(1) A driver's license or state-issued identification card that includes the mother's current residence on the face of the license/card;
(2) A rent receipt that includes the mother's name and address;
(3) Any type of utility, telephone, or other bill that includes the mother's name and address; or
(4) Other evidence acceptable to the State Registrar.
b. If the birth occurred outside of the mother's place of residence and the mother is a resident of the Commonwealth of Virginia, such evidence shall consist of the following:
(1) An affidavit from the owner, supervisor, manager and tenant of the premises where the birth occurred stating that the mother was present on those premises at the time of the birth;
(2) Evidence of the affiants' residence similar to that required in subdivision 3 of this subsection; and
(3) Evidence of the mother's residence in the Commonwealth of Virginia similar to that required in subdivision 3 a of this subsection.
c. If the mother is not a resident of the Commonwealth of Virginia, evidence that the home birth took place in Virginia must consist of clear and convincing evidence acceptable to the State Registrar, such as affidavits of the persons present at the time of the birth, proof of such affiants' residence as set out in subdivision 3 a of this subsection, ambulance records, police records, or the like.
Statutory Authority
§§ 32.1-12 and 32.1-250 of the Code of Virginia.
Historical Notes
Derived from VR355-29-100 § 3.1, eff. April 1, 1995; amended, Virginia Register Volume 19, Issue 26, eff. October 8, 2003.
12VAC5-550-110. Death certificate items.
The certificate of death to be used shall be the Certificate of Death, Commonwealth of Virginia, and shall contain the following items: full name of decedent; place of death; usual residence; date of death; sex; hispanic origin, if any, and race; education; date of birth; age; birthplace; citizenship; usual occupation and industry; veteran status; social security number or control number issued by the Department of Motor Vehicles; father's name; mother's maiden name; marital status and name of spouse, if married or widowed; informant's name and relationship to decedent; medical certification of cause of death; autopsy; if female, was there a pregnancy during past three months; and supplementary data concerning death due to external causes; certification of attending physician or medical examiner, including title, address, and date signed; disposition of the body; signature of funeral service licensee; name and address of funeral home; date received by registrar; registrar's signature; registration area and certificate numbers; and state file number.
Statutory Authority
§§ 32.1-12 and 32.1-250 of the Code of Virginia.
Historical Notes
Derived from VR355-29-100 § 3.2, eff. April 1, 1995; amended, Virginia Register Volume 19, Issue 26, eff. October 8, 2003.
12VAC5-550-120. Fetal death or induced termination of pregnancy report items.
A. The Report of Fetal Death Commonwealth of Virginia, and shall contain the following items for spontaneous fetal deaths: place of occurrence; usual residence of patient (mother); full maiden name of patient; medical record number and social security number of patient; hispanic origin, if any, and race of patient; age of patient; education of patient; sex of fetus; patient married to father; previous deliveries to patient; single or plural delivery and order of plural delivery; date of delivery; date of last normal menses and physician's estimate of gestation; weight of fetus in grams; month of pregnancy care began; number of prenatal visits; when fetus died; congenital malformations, if any; events of labor and delivery; medical history for this pregnancy; other history for this pregnancy; obstetric procedures and method of delivery; autopsy; medical certification of cause of spontaneous fetal death; signature of attending physician or medical examiner including title, address and date signed; method of disposal of fetus; signature and address of funeral service licensee or hospital representative; date received by registrar; registrar's signature; registration area and report numbers.
B. The Report of Induced Termination of Pregnancy, Commonwealth of Virginia, and shall contain the following items for induced terminations of pregnancy: place of occurrence; usual residence of patient; patient identification number; age of patient; hispanic origin, if any, and race of patient; education of patient; patient married to father; date of pregnancy termination; pregnancy history of patient; date of last normal menses and physician's estimate of gestation; type of termination procedures; pregnancy terminated because of genetic defect; signature, title, and address of person completing this report; registration area and report numbers.
Statutory Authority
§§ 32.1-12 and 32.1-250 of the Code of Virginia.
Historical Notes
Derived from VR355-29-100 § 3.3, eff. April 1, 1995; amended, Virginia Register Volume 19, Issue 26, eff. October 8, 2003.
12VAC5-550-125. Certificate of birth resulting in a stillbirth.
In accordance with § 32.1-258.1 of the Code of Virginia, a certificate of birth resulting in a stillbirth shall be issued upon request from the parent for a fetal death of 20 weeks or more gestation and payment of the appropriate fee for a vital record. This certificate shall contain the following information; name (optional), mother's maiden name, father's name (if indicated), date of event, and hospital of occurrence. When no report of spontaneous fetal death is available to establish the event, documentation from the following sources is acceptable: physician or licensed nurse midwife who provided care to the mother, documentation from the medical record maintained at the hospital of occurrence, copy of the report of spontaneous fetal death or documentation from funeral service director (if such services were provided).
Statutory Authority
§§ 32.1-12 and 32.1-250 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 19, Issue 26, eff. October 8, 2003.
12VAC5-550-130. Marriage return and certificate items.
The record of marriage to be used shall be the Marriage Return and Certificate, Commonwealth of Virginia, and shall contain the following items: city or county of the court of issuance; court clerk's number; for the groom: full name, age, date and place of birth, social security number or control number issued by the Department of Motor Vehicles, race, marital status if previously married, number of marriage, education, usual residence, the names of parents; for the bride: full name, maiden name, age, date and place of birth, social security number or control number issued by the Department of Motor Vehicles, race, marital status if previously married, number of marriage, education, usual residence, and names of parents; signature of clerk of court and date of license; date and place of marriage; whether civil or religious ceremony; certification and signature of officiant indicating title, address, and year and court of qualification; date received by clerk of court from officiant; and state file number.
Statutory Authority
§§ 32.1-12 and 32.1-250 of the Code of Virginia.
Historical Notes
Derived from VR355-29-100 § 3.4, eff. April 1, 1995; amended, Virginia Register Volume 19, Issue 26, eff. October 8, 2003.
12VAC5-550-140. Report of divorce or annulment items.
The report of divorce or annulment to be used shall be the Report of Divorce or Annulment, Commonwealth of Virginia, and shall contain the following items: city or county of court of issuance; for the husband: full name, date and place of birth, social security number or control number issued by the Department of Motor Vehicles, education, number of marriage, usual residence; for the wife: full maiden name, date and place of birth, social security number or control number issued by the Department of Motor Vehicles, education, number of the marriage, usual residence; date and place of marriage; identity of plaintiff and to whom divorce granted; number and custody of children under 18 in this family; date of separation; date of divorce; legal grounds or cause of divorce; signature of attorney or petitioner; certification and signature of clerk of court indicating type of decree; court file number; date final order entered; and state file number.
Statutory Authority
§§ 32.1-12 and 32.1-250 of the Code of Virginia.
Historical Notes
Derived from VR355-29-100 § 3.5, eff. April 1, 1995; amended, Virginia Register Volume 19, Issue 26, eff. October 8, 2003.