Still Birth Extract Application by mikeholy

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									  I:       . _
               General Register Office



            people
                        for
                   SCOTLAND
                      about Scotland'.
                                                                         Completed Forms should be sent to
                                                                         General Registration Unit
                                                                         New Register House
                                                                         3 West Register Street
                                                                         Edinburgh
                                                                         EH1 3YT
                                                                         Contact Tel No. 0131 3144455




Still-Birth Extract Application - Scotland
(PleaseNote:You must be a parentof the child to apply.Siblingswill be consideredwith
the expressconsentof a parentor in the eventof the parents'death)

STill-BIRTH             DETAilS:

Name:

Sex:

Date of Still-Birth:

Place of Still-Birth:

Mother's     Name & Maiden Surname:

Mother's     Address     at time of Still-Birth:

Father's     Name:

Date & Place of Parents'         Marriage(if applicable):

Date and place of birth of any siblings              (if applicable)




APPLICANT'S DETAilS:
(Please state your relationship)


MOTHER               D FATHER D                            SIBLING            D
Name:
Address:

Telephone      Number:                                         E-mail:
Signature:                                                     Date:


                                     www.gro-scotland.gov.uk
FEES: The current fee for a Still-Birth Extract is £10.00
PAYMENT DETAilS:

You may pay by cheque or postal order In British pounds Sterling, crossed and
made payable to 'The Registrar General'. PLEASE DO NOT SEND CASH. You can
also pay by Maestro, Visa or Mastercard by completing the appropriate sections
below.

Card Number

CIIIJ CIIIJ CIIIJ CIIIJ
Security Code            [II]                                                               Start Date ....•• 1••••••                                                          Expiry Date ••.... 1••••••

Issue Number             1                                           1          Maestro Transactions                                                           Only-                                  ~
                                                                                (Last 3 numbers If Maestro 19 digit card)                                                                             ~

Cardholder's         Name •••••••••••••••••.•                               1' ••••       '. I' I' I' I' ••.•••••••••     I' ••••••••               I' •••••        I' •••••          1' ••   I' ••••••••               I' I' I' 1' ••   1' ••   1' •••••••               1'"




Cardholder's         Address.   I' I'   1'.'   I' I' I' I' I' I' I' 1' ••     1' ••••••••••••••••••••••••••                                 1' ••     I'.i     ••   I' 1'.   1' •••     I' I' I' I' 1'.   I' 1' ••   _.I'    •••••         1' •••••           I' ••••••


(if different from applicant)


                             NOT TO 8,e COMPLETED BY APPLICANT
                                   (FOR OFFICE USE ONt Y)

Search By                                                                             ,                                                              Date                                                                                                                   .

Registration       Districts Searched:

(District Name)                                                                                                                     (District Number)




                                                                                                                                        ••••••        , ••• _., ••••.•••••••••••••••••.•••••••••••••••.•••••••                                                             i,




Entry No       '                                                                                         '"                         R.C.E. No                                                                                                                                   .

Se nt to Type                                                                                                  .                    Rece.ved                                                                                                                                    .

Fees:
Chequel Po/CreditlDebit         Card (£)                           I                                               I Number               of extracts req uired                                                                                                                 .

Fees banked by                                                                                                                           Date                                                                                                                               .


Refunds: Amount to be refunded (£) 1                                                                                    1 Passed to                                                                                          on                                            .


Entry Se·nt    By                                                                                                                        Date                                                                ,                       ,                        ,                 .

                                                                         www.gro-scotland.gov.uk

								
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