Tennessee Application for Certificate of Birth Resulting in Stillbirth (PH-4107)
Official state formStillbirth and pregnancy lossForm PH-4107Free downloadLast verified November 10, 2026
Request to the Tennessee Office of Vital Records for a certificate of a stillbirth. The $15.00 search fee includes one copy if the record is found and is charged even if no record is found.
Who can use this form
- The mother or the father makes the request and signs the form.
- Unless the form is notarized, the requester sends a photocopy of a government issued ID showing their signature.
What to send with it
- The completed form, with the details of the stillbirth and the date and place of delivery.
- $15.00 for each copy, by check or money order payable to Tennessee Vital Records. Do not send cash.
- A photocopy of a government issued ID showing your signature, unless the form is notarized.
- The name and address where the copy should be mailed.
Where to send it
- Mail to
- Tennessee Vital Records 710 James Robertson Parkway 1st Floor, Andrew Johnson Tower Nashville, TN 37243-1219
- State fee
- $15.00 for each copy, as printed on the form. The search fee is charged even if no record is found.
- Typical processing
- Not provided
- Form revision
- Revised 2/2019
- Source
- Official government page