Utah Optional Reporting of Early Term Stillbirth and Application for Certificate, 16-19 Weeks of Pregnancy (DHHS-OVRS-107)
Official state formStillbirth and pregnancy lossForm DHHS-OVRS-107Free downloadLast verified November 10, 2026
Optional report of an early term stillbirth at 16 to 19 weeks of pregnancy, combined with the application for a certificate. A medical provider signs the report section. It is sent to the Utah Office of Vital Records and Statistics.
Who can use this form
- A parent of an early term stillborn child delivered between 16 and 19 weeks of gestation
- A medical provider (MD, DO or PA) completes and signs the provider section
What to send with it
- The completed form, with the medical provider's signature
- Picture ID and the required fee, per the office's records page
Where to send it
- Mail to
- Office of Vital Records and Statistics PO Box 141012 SLC, UT 84114-1012
- State fee
- $18.00 for one certified copy. Additional certified copies $10. Standard U.S. shipping $1. Expedited processing $25. Expedited shipping (U.S. only) $30.
- Typical processing
- Not provided
- Form revision
- 2026
- Source
- Official government page