Sample Certificate Of Live Birth -State Of California
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1C ERTIF I C ATE OF LIV E BI RT H
S TATE O F CALIFOR NIA
STATE FILE NUMBER
US E BL A CK INK ONLY
LOCAL REGISTRATION NUMBER
1
. A
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1
. B
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1C. LAST
2. SEX
3A. THIS BIRTH, SINGLE, TWIN, ETC.
3B. IF MULTIPLE, THIS CHILD 1ST, 2ND, ETC.
4A. DATE OF BIRTH - MM/DD/CCYY
4B. HOUR - 24 HOUR CLOCK TIME
SAMPLE
A 5
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5C. CITY
5D. COUNTY
A 6
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6
. B
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6
. C
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7. BIRTHPLACE - STATE/ COUNTRY
8. DATE OF BIRTH - MM/DD/CCYY
A 9
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9
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9
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10. BIRTHPLACE - STATE/ COUNTRY
11. DATE OF BIRTH - MM/DD/CCYY
1
A 2
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12C. DATE SIGNED - MM/DD/CCYY
I CERTIFY THAT I HAVE REVIEWED THE STATED
INFORMATION AND THAT IT IS TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE.
13A. ATTENDANT/CERTIFIER - SIGNATURE AND DEGREE OR TITLE
13B. LICENSE NUMBER
13C. DATE SIGNED - MM/DD/CCYY
I CERTIFY THAT THE CHILD WAS BORN ALIVE AT
THE DATE, HOUR, AND PLACE STATED.
13D. TYPED NAME, TITLE AND MAILING ADDRESS OF ATTENDANT
14. TYPED NAME AND TITLE OF CERTIFIER IF OTHER THAN ATTENDANT
16. LOCAL REGISTRAR - SIGNATURE
15A. DATE OF DEATH - MM/DD/CCYY
15B. STATE FILE NO. - STATE USE ONLY
17. DATE ACCEPTED FOR REGISTRATION - MM/DD/CCYY
CONFIDENTIAL INFORMATION FOR PUBLIC HEALTH USE ONLY
19. FATHER HISPANIC, LATINO, OR SPANISH?
18. RACE - UP TO THREE RACES/ETHNICITIES MAY BE LISTED. SEE WORKSHEET ON BACK.
20C. EDUCATION - HIGHEST LEVEL OR DEGREE
20. DATE LAST WORKED - MM/CCYY
2
A 0
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NDUSTRY
SAMPLE
21. RACE - UP TO THREE RACES/ETHNICITIES MAY BE LISTED. SEE WORKSHEET ON BACK.
22. MOTHER HISPANIC, LATINA, OR SPANISH?
23C. EDUCATION - HIGHEST LEVEL OR DEGREE
2
A 3
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2
B 3
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NDUSTRY
23. DATE LAST WORKED - MM/CCYY
4 2
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24C. CITY
4 2
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Y
2
E 4
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25A. DATE LAST NORMAL MENSES BEGAN
25AA. DATE FIRST PRENATAL CARE VISIT
25B. MONTH PRENATAL CARE BEGAN
25BA. DATE LAST PRENATAL CARE VISIT
25C. NUMBER OF PRENATAL CARE VISITS
25D. PRINCIPAL SOURCE OF PAYMENT
FOR PRENATAL CARE
26. BIRTHWEIGHT - GRAMS
27. PREGNANCY HISTORY - COMPLETE EACH SECTION
PREVIOUS LIVE BIRTHS - DO NOT INCLUDE THIS CHILD
OTHER TERMINATIONS - EXCLUDE INDUCED ABORTIONS
A. NUMBER NOW LIVING
B. NUMBER NOW DEAD
D. NUMBER BEFORE 20 WEEKS
E. NUMBER AFTER 20 WEEKS
26A. OBSTETRIC ESTIMATION OF GESTATION AT DELIVERY -
COMPLETED WEEKS
26B. HEARING SCREENING
C
D .
A
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O
F
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L
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8 2
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2
B 8
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X
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URCE OF PAYMENT FOR DELIVERY
29. COMPLICATIONS AND PROCEDURES OF PREGNANCY AND CONCURRENT ILLNESSES
0 3
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31. abnormal conditions and clinical procedures related to the newborn
A
B
C
D
E
F
CENSUS TRACT
32. FATHER/PARENT SOCIAL SECURITY NUMBER
33. MOTHER/PARENT SOCIAL SECURITY NUMBER
VS 10D (REV. 1/07)
PR IVACY NOTIFICATION
This information is collected by the State of California, Department of Health Services, Office of Vital Records, MS 5103, PO Box 997410, Sacramento, CA
95899-7410. The information is required by Division 102 of the Health and Safety Code. This record is open to public access except where prohibited by statute.
Every element on this form, except items 18 through 23C, 32, and 33, is mandatory. Failure to comply is a misdemeanor. The principal purposes of this record
are to: 1) Establish a legal record of each vital event; 2) Provide certified copies for personal use; 3) Furnish information for demographic and epidemiological
studies; and 4) Supply data to the National Center for Health Statistics for federal reports. Items 32 and 33 are included pursuant to Section 102425(b)(14) of
the Health and Safety Code, and may be used for child support enforcement purposes.
Definition of Live Birth
"Live Birth" means the complete expulsion or extraction from its mother of a product of conception (irrespective of duration of pregnancy) which, after such
separation, breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles,
whether or not the umbilical cord has been cut or the placenta is attached.
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