Wisconsin Application to Purchase a Copy of a Certificate of Birth Resulting in a Stillbirth (F-05009)
Official state formStillbirth and pregnancy lossForm F-05009Free downloadLast verified November 10, 2026
A parent uses this form to file for and buy a Certificate of Birth Resulting in a Stillbirth, or to get another copy of one already on file. It is mailed to the Wisconsin State Vital Records Office.
Who can use this form
- Only a parent of the stillborn child can file and get this certificate (Wis. Stat. § 69.145)
- The fetus must have been 20 weeks or more in gestational age, or 350 grams or more in weight, at delivery
What to send with it
- The completed form, signed by the parent or parents
- The third-party statement on the form, completed and signed by a designee of the hospital, the clinic or attending physician's office, or the midwife who attended. It is not required for another copy of a certificate already on file
- Acceptable identification (the form does not list which IDs are accepted)
- A check or money order payable to STATE OF WIS. VITAL RECORDS
- A self-addressed, stamped, business-size envelope
Where to send it
- Mail to
- STATE VITAL RECORDS OFFICE PO BOX 309 MADISON, WI 53701
- State fee
- $10.00 for the first copy, which covers filing and the first copy; $3.00 for each additional copy issued at the same time. The fees are the same for another copy of a certificate already on file.
- Typical processing
- Not provided
- Form revision
- Rev. 05/2021
- Source
- Official government page