Certificate of Fetal Death (COFD)

Municipal Form No.
103A (To be accomplished in quadruplicate) REMARKS/ANNOTATION

(Revised January 1993)
Republic of the Philippines
CERTIFICATE OF FETAL DEATH
(Fill out completely and legibly. Use ink or typewriter.
Place X before the appropriate answer in items 2, 5a, 5b, 5c, 20, 22a, 23 and 25.)
Province ________________________________________ Registry No.
City/Municipality __________________________________
1. NAME OF FETUS (First) (Middle) (Last) TO BE FILLED UP AT THE
(if given) OFFICE OF THE CIVIL
REGISTRAR
F
2. SEX 3. DATE OF DELIVERY (day) (month) (year) 2
E ______1. Male ______ 2. Female
T ______ 3. Undetermined
U 4. PLACE OF (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province)
S DELIVERY House No., Street, Barangay)
9
5a. TYPE OF DELIVERY b. IF MULTIPLE DELIVERY, FETUS WAS
______1 Single ______2 Twin ______ 1 First ______ 2 Second
______ Triplet, etc. _______ 3 Others, Specify _______
c. METHOD OF DELIVERY d. BIRTH ORDER(live births and fetal e. WEIGHT 10 11
_____ 1 Normal spontaneous vertex deaths including this delivery)
OF FETUS
_____ 2 Other (specify) ____________ __________ (first, second, third, etc.)
______ grams
M 6. MAIDEN (First) (Middle) (Last)
O
NAME 17
T 7. CITIZENSHIP 8. RELIGION 9. OCCUPATION 10. Age at the
time o this delivery:
H ______ years
E
R 11a. Total number of
b. No. of Children still c. No. of Children 22
children born living: born alive but
alive: ____________ _____________ are now dead: ______________
12. RESIDENCE (House No./Street/Barangay) (City/Municipality) (Province)
23 24 26
F 13. NAME (First) (Middle) (Last)

A
T
H 30 31 32 35
14. CITIZENSHIP 15. RELIGION 16. OCCUPATION 17. Age at the
E time o this delivery:
R ______ years
18. DATE AND PLACE OF MARRIAGE OF PARENTS (if applicable)
37 39 41
MEDICAL CERTIFICATE
19. CAUSES OF FETAL DEATH
a. Main disease/condition of fetus _____________________________________________________
b. Other diseases/conditions of fetus ___________________________________________________
43
c. Main maternal disease/condition affecting fetus _________________________________________
d. Other maternal disease/condition affecting fetus ________________________________________
e. Other relevant circumstances _______________________________________________________
20. FETUS DIED: _______ 1 Before Labor _______ 2 During labor/delivery _______3 Unknown 48 49 50 53
21. LENGTH OF PREGNANCY: ______________ Completed Weeks
22a. ATTENDANT: ___ 1 Physician ___ 2 Nurse ____ 3 Midwife ____ 4 Hilot (Traditional Midwife)
____ 5 Others (Specify) _______________________________ _____ 6 None
55
22b. CERTIFICATION
I hereby certify that the foregoing particulars are correct as near as same can ascertained and
I further certify that the fetus was born dead at ________ am/pm on the date indicated above.
REVIEWED BY: 56
Signature _______________________________
Name in Print ____________________________
__________________________________
Title or Position __________________________ Signature over printed name
Address ________________________________ of Health Officer
___________________________________ 60
Date ___________________________________ _____________________________
Date
23. CORPSE DISPOSAL 24. BURIAL/CREMATION PERMIT 25. AUTOPSY

_____ 1 Burial ______ 2 Cremation Number _______________________ _____ 1 Yes 64
_____ 3 Others (specify) __________ Date Issued ____________________ _____ 2 No
26. NAME AND ADDRESS OF CEMETERY OR CREMATORY
27. INFORMANT
Signature ______________________________________ Address ___________________________________ 65
Name in Print ___________________________________ ___________________________________
Relationship to the fetus __________________________ Date ____________________________________
28. PREPARED BY 29. RECEIVED AT THE OFFICE OF

THE CIVIL REGISTRAR
Signature _____________________________________ 67
Name in Print __________________________________
Title or Position ________________________________
Date _________________________________________
FETAL DEATH is death prior to the expulsion or extraction from its mother of a product of
conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after
such separation, the fetus does not breathe or show any other evidence of life such as beating of the
heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.
POSTMORTEM CERTIFICATE OF DEATH
I HEREBY CERTIFY that I have performed an autopsy upon the body of the deceased this
_________ day of _________________________, _______________ and that the cause of death
was as follows: _________________________________________________
________________________________________________________________________________
_____________________________ ___________________________
Signature Title/Designation
_____________________________ ___________________________
Name in Print Address

Certificate of Fetal Death (COFD)

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Certificate of Fetal Death (COFD)

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Municipal Form No.

103A (To be accomplished in quadruplicate) REMARKS/ANNOTATION

F 13. NAME (First) (Middle) (Last)

23. CORPSE DISPOSAL 24. BURIAL/CREMATION PERMIT 25. AUTOPSY

26. NAME AND ADDRESS OF CEMETERY OR CREMATORY

28. PREPARED BY 29. RECEIVED AT THE OFFICE OF

POSTMORTEM CERTIFICATE OF DEATH

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