New York Application for Certificate of Still Birth (DOH-5056)
Official state formStillbirth and pregnancy lossForm DOH-5056Free downloadLast verified November 10, 2026
Notarized application to request a Certificate of Still Birth from the New York State Department of Health. It is sent to the Bureau of Vital Records in Albany. No fee is required.
Who can use this form
- A parent listed on the pregnancy loss record.
- A parent or sibling of a listed parent (the stillborn child's grandparent, aunt or uncle), only if both parents of the stillborn child are deceased.
- The applicant signs in front of a notary public.
What to send with it
- The completed form, signed and notarized.
- If you are not a parent on the pregnancy loss record: documentation of the parents' deaths and of your relationship.
- The name and address where the record should be sent and the number of copies requested.
Where to send it
- Mail to
- New York State Department of Health Bureau of Vital Records P.O. Box 2602 Albany, NY 12220-2602
- State fee
- No fee is required.
- Typical processing
- Not provided
- Form revision
- 04/26
- Source
- Official government page