Washington Certification of Birth Resulting in Stillbirth Order Form (DOH 422-234)
Official state formStillbirth and pregnancy lossForm DOH 422-234Free downloadLast verified November 10, 2026
Use this form to order a Washington Certification of Birth Resulting in Stillbirth. Only the individual who gave birth can receive one. It is mailed with a copy of ID and payment to the Center for Health Statistics at the Washington State Department of Health.
Who can use this form
- Only the individual who gave birth to the child
- The applicant must provide identity documentation and sign the sworn statement on the order form
What to send with it
- The completed order form, signed and dated
- A copy of your identity document
- A check or money order made payable to DOH. Certificate purchases are nonrefundable
- If you send the order with a correction request, the form gives a different address: Center for Health Statistics, Attn: Corrections, PO Box 47814, Olympia, WA 98504-7814
Where to send it
- Mail to
- Department of Health Center for Health Statistics PO Box 9709 Olympia, WA 98507
- State fee
- $25 per certificate; $15 per apostille. First class mail at no additional charge.
- Typical processing
- Not provided
- Form revision
- November 2025
- Source
- Official government page