Tennessee Worksheet and Application for Commemorative Certificate of Nonviable Birth (PH-4347)
Official state formStillbirth and pregnancy lossForm PH-4347Free downloadLast verified November 10, 2026
Worksheet and application for a commemorative certificate of a nonviable birth. A licensed healthcare practitioner or designee verifies the information. It is mailed to the Tennessee Office of Vital Records.
Who can use this form
- Only the patient of a nonviable birth may request a commemorative certificate.
- A licensed healthcare practitioner or designee must verify and sign the information on the form.
What to send with it
- The completed worksheet and application, signed by the requestor.
- The signature and date of the licensed healthcare practitioner or designee who verifies the information.
- A photocopy of your photo ID, such as a current driver's license.
- Payment for certified copies, which the form lists at $15 each. Checks are payable to Vital Records.
Where to send it
- Mail to
- Office of Vital Records First Floor, Andrew Johnson Tower 710 James Robertson Parkway Nashville, TN 37243
- State fee
- Certified copies are $15 each, as printed on the form. The form says fees can change and tells readers to check the office's website. No separate fee for the commemorative certificate is printed.
- Typical processing
- Not provided
- Source
- Official government page