Iowa Application Request for Certificate of Nonviable Birth
Official state formStillbirth and pregnancy lossFree downloadLast verified November 10, 2026
Request form a patient uses to order a Certificate of Nonviable Birth. It is mailed to the Bureau of Health Statistics with the Certification of Nonviable Birth from the health care provider.
Who can use this form
- Only the patient who experienced the nonviable birth
- The nonviable birth must have occurred on or after January 1, 2000
What to send with it
- This request form, signed in front of a notary public
- The completed Certification of Nonviable Birth form from the health care provider or hospital
- A copy of your government-issued photo ID
- The $15 fee by check or money order
Where to send it
- Mail to
- Iowa Department of Health and Human Services Bureau of Health Statistics 321 E. 12th St, Lucas State Office Building Des Moines IA 50309
- State fee
- $15
- Typical processing
- The bureau issues the certificate within 60 days of receiving the certification and the completed request.
- Form revision
- Updated 06/2025
- Source
- Official government page