Professional Documents
Culture Documents
Statement of Live Birth: Vital Statistics Act
Statement of Live Birth: Vital Statistics Act
Statement of Live Birth: Vital Statistics Act
Registrar General
Statement of Live Birth
and Consumer Services
189 Red River Road Form 2
This is a permanent legal record. PO Box 4600 Vital Statistics Act
Please read all instructions before completing this form. Thunder Bay ON P7B 6L8
Type or print clearly in blue or black ink and complete all items.
Section A - Child’s Information (see instruction #1) If the child is being given a Single Name you must follow instruction #1b
Last Name or Single Name Sex of Child
Date of Birth (yyyy/mm/dd) Name of hospital (if not hospital give exact location where birth occurred)
Any Previous Legal Last Name(s) or Single Name(s) Place of Birth (City/Town/Village/Township) / (Province/Country)
I agree that the child’s last name or single name will be as shown in Section A Yes No
I certify the statements made on this form are true and correct and I am aware that it is an offence to wilfully make false statements. Date (yyyy/mm/dd)
X
Section C - Mother Father Parent (see instruction #4)
Current Legal Last Name or Single Name Legal Last Name or Single Name at Birth
Any Previous Legal Last Name(s) or Single Name(s) Place of Birth (City/Town/Village/Township) / (Province/Country)
I agree that the child’s last name or single name will be as shown in Section A Yes No
I certify the statements made on this form are true and correct and I am aware that it is an offence to wilfully make false statements. Date (yyyy/mm/dd)
X
Section D - Birth Information (if none of the parents on this form is the birth parent, see instruction #5b)
Residence of Parent in Section B - Complete street address (City, town, village, township - if rural give Post Office or Rural Route address) Postal Code
Mailing Address of Parent in Section B if different from above - Complete street address (If rural give Post Office or Rural Route address) Postal Code
Duration of Total number of children ever born Weight of child at birth Kind of Birth If multiple birth, state
pregnancy to this parent including this birth whether this child was
(in weeks) Grams born 1st, 2nd, 3rd, etc.
Of this Total, Number born live Single Twin
Of this Total, Number stillborn or lb. oz.
Triplet Other
Name of Attendant at birth
Physician Midwife Other, specify:
X
Office Use Only
11022E (2021/07) © Queen's Printer for Ontario, 2021 Save Form Disponible en français Clear Form Print Form
Ministry of Government Office of the
and Consumer Services Registrar General
Personal information contained on this form is collected under the authority of the Vital Statistics Act, R.S.O. 1990,
c.V.4 as amended, and may be used to register and record births, stillbirths, deaths, marriages, additions or changes
of name, corrections or amendments, provide certified copies, extracts, certificates, search notices, and photocopies
and for statistical, research, medical, law enforcement, adoption and adoption disclosure purposes as applicable.
Questions about this collection of information should be directed to: The Deputy Registrar General, Office of the
Registrar General, 189 Red River Road, PO Box 4600, Thunder Bay ON P7B 6L8. Telephone: Outside Toronto but
within North America toll free 1-800-461-2156 or in Toronto or outside North America 416-325-8305,
TTY/Teletypewriter (for the hearing impaired) 416-325-3408.