Fillable Printable Apply For Recognition Of Loss
Fillable Printable Apply For Recognition Of Loss
Apply For Recognition Of Loss
Recognition of early
pregnancy loss
Form 21 Application for Recognition of Early Pregnancy Loss. Effective as of 20 September2016Page 1 of3
General inform ati o n
Eligibility
You are eligible to commemorate your
family’s early pregnancy loss if:
•Your loss took place in NSW.
•Your loss took place before 20 weeks or, if
weeks are unknown, your baby weighed less
than 400g.
•Your treating medical practitioner or midwife is
available to sign the declaration.
Complet ing this form
•You can complete thisform online, and print
out a copy to sign.
•Your treating medical practitioner or midwife
must sign the health professional’s
declaration.
•You can then lodge the application either by
email, post or in person.
•Recognition of early pregnancy loss is free.
Please visit our website for turnaround times,
which are the same as standard certificates.
Privacy
Your ri ght t o privacy
Registry records are not available for public
scrutiny.
The information held by the Registry may be used
for statistical purposes and by law enforcement
agencies, as well as other uses provided for by
law. Such access for approved purposes may be
granted to other Registries and certain
government orauthorised non-government
agencies.
Disclosure of information
When you complete this application form,
understand that you have consented to the
release of information provided by you, to those
agencies who may be able to validate that
information in support of your application.For
more information on privacy and disclosure,
please visit our website
Options to lodge
By post
•NSW Reg ist r y of Birt h s Deat h s & Marr iages
GPO Box 30, Sydney NSW 2001
In Pers on
•Registry ofBirths Deaths & Marriagesoffice.
Monday to Friday: 8:00am – 4:30pm
35 Regent Street, Chippendale
160 Marsden Street, Parramatta
•At a Service NSW Service Centre.
www.service.nsw.gov.au
Contacting us
•NRS: 1300 555 727(Speech/hearing impaired)
•TIS: 131 450 (Translating/interpreting service)
•Email: bdm-epl@justice.nsw.gov.au
Phone: 13 77 88
www.bdm.nsw.gov.au
Recognition of early
pregnancy loss
Form 21 Application for Recognition of Early Pregnancy Loss. Effective as of 20 September2016Page 2 of3
Application
Bab y’s nameIfyou choose not to provide a name the certificate will show “Baby of…” parent’s name/s.
First given name
Other given names
Family name
PlaceWe understand that due to circumstances you may not be able to provide all the details.
Suburb/Town/City
State/Territory
DateGestation in weeksWeight of baby
Mother’s details
Mother’s name (Parent One)Mandatory fields are marked*
*First given name
Other given names
*Family name*Age i n years
Parent Two’s details
Firstgiven name
Other given names
Family nameAge in years
Applicant details
*Relationship to baby (select one):MotherFatherParent
Your postal address
*Address
*Suburb/Town/City
*State/Territory*Postcode
Contact details
*Telephone nu m b er*Mobile number
*Email address
Applicant’s Declaration
I declare that the information I have provided is true and correct. I certify that I have read and understand ‘Your Right
to Privacy’ and ‘Disclosure of Information’on the previous page. I acknowledge the ‘Recognition of early pregnancy
loss’ I receive is not a legal document.
Signature of Applicant*Date
dd / mm / yyyy
Recognition of early
pregnancy loss
Form 21 Application for Recognition of Early Pregnancy Loss. Effective as of 20 September2016Page 3 of3
Health professi onal ’ s declaration
Declaration to be completed by the treating medical practitioner or midwife
Mandatory fields are marked*
Name
Title:*Dr*Mr*MrsMs*Other*
*First given name
*Family name
Contact details
*Telephone nu m b er
*Mobile number
*Email address
Provider details
Provider number
Qualifications
Details of early pregnancy loss
The loss took place in NSW
The loss took place before 20 weeks or, if weeks are unknown, the baby weighed less than 400g
Date of loss
dd / mm / yyyy
Declaration
I declare that all statements made in this declaration are true and correct.
Signature of medical
*Date
dd / mm / yyyy
practitioner or midwife
Privacy note
For further information on Privacy and Disclosure, please refer to page 1.
