Vital Statistics Regulations

The content of forms to be used in the administration of the Act and these regulations is set out in Schedule A.

For the purposes of section 3,

The Health Information Act applies in respect of disclosure by the Registrar General of personal health information for a research purpose. R-090-2015,s.3.

SCHEDULE A (section 1)

Content of Forms

Part 1 - Birth Registration Statement

1. Information in respect of the child: (a) surname; (b) given names; (c) sex; (d) date of birth; (e) place of birth; (f) weight of child in grams; (g) kind of birth (single or multiple) and, if a multiple birth, (i) the number of children born, (ii) the child’s birth order.

2. Information in respect of the parents: (a) in respect of the mother, (i) surname at mother’s birth, (ii) given names, (iii) date of birth, (iv) place of birth, (v) ethnicity (to be indicated as "optional"), (vi) duration of pregnancy in respect of the child whose birth is to be registered, (vii) total number of live born children, including previous children and the child whose birth is to be registered, (viii) total number of previous stillborn children, (ix) mailing address and telephone number; (b) in respect of the father or other parent, (i) surname at father’s or other parent’s birth, (ii) given names, (iii) date of birth, (iv) place of birth, (v) ethnicity (to be indicated as "optional"), (vi) mailing address and telephone number; (c) an indication of whether parents are legally married and particulars of the marriage (to be indicated as "optional").

3. Information in respect of the health care professional, if any, in attendance at the time of birth: (a) surname and given names; (b) designation of health care professional (physician, midwife, nurse, other); (c) mailing address.

4. Certification of parents:

(b) signature of father or other parent and date signed; (c) an indication of whether the parents consent to disclosure of information to the Canada Revenue Agency for the purpose of determining whether a person is or is not entitled to benefits provided under the Income Tax Act (Canada) or the Universal Child Care Benefit Act (Canada); (d) an indication of whether the parents consent to disclosure of information to any department or agency of the Government of Canada, including any branch, division or institution of the department or agency, responsible for administering the Social Insurance Register under the Department of Employment and Social Development Act (Canada) or assigning Social Insurance Numbers under the Department of Employment and Social Development Act (Canada) and the Employment Insurance Act (Canada), for the purpose of determining whether a person is or is not eligible for a Social Insurance Number.

5. Certification of Registrar General and administrative information: (a) signature of Registrar General and date signed; (b) registration number assigned by the Registrar General. Part 2 - Birth Registration Statement for Custom Adoption

(c) sex; (d) date of birth; (e) place of birth; (f) weight of child in grams; (g) kind of birth (single or multiple) and, if a multiple (i) the number of children born, (ii) the child’s birth order.

2. Information in respect of the adoptive parents: (a) in respect of the mother, (i) surname at mother’s birth, (ii) given names, (iii) date of birth, (iv) place of birth, (v) ethnicity (to be indicated as "optional"), (vi) total number of previous live born children, (vii) total number of previous stillborn children, (viii) mailing address and telephone number; (b) in respect of the father or other parent, (i) surname at father’s or other parent’s birth, (ii) given names, (iii) date of birth, (iv) place of birth, (v) ethnicity (to be indicated as "optional"), (vi) mailing address and telephone number; (c) an indication of whether parents are legally married "optional").

3. Information in respect of the birth parents: (a) in respect of the birth mother, (i) surname at mother’s birth, (ii) given names, (iii) date of birth, (iv) duration of pregnancy; (b) in respect of the birth father or other parent, (i) surname at father’s or other parent’s birth, (ii) given names, (iii) date of birth. Partie 2 - Déclaration d’enregistrement de naissance dans le

c) le sexe; d) la date de naissance; e) le lieu de naissance; f) le poids de l’enfant en grammes; g) le genre de naissance (simple ou multiple) et, dans (i) le nombre d’enfants nés, (ii) le rang de l’enfant dans l’ordre de naissance.

2. Renseignements concernant les parents adoptifs : a) concernant à la mère, (i) le nom de famille à la naissance, (ii) les prénoms, (iii) la date de naissance, (iv) le lieu de naissance, (v) l’ethnicité (à titre «facultatif»), (vi) le nombre total des autres enfants nés vivants, (vii) le nombre total des autres enfants mort-nés, (viii) l’adresse postale et le numéro de téléphone; b) concernant le père ou l’autre parent, (i) le nom de famille à la naissance, (ii) les prénoms, (iii) la date de naissance, (iv) le lieu de naissance, (v) l’ethnicité (à titre «facultatif»), (vi) l’adresse postale et le numéro de téléphone; c) indiquer si les parents sont légalement mariés et

3. Renseignements concernant les parents naturels : a) concernant la mère naturelle, (i) le nom de famille à la naissance, (ii) les prénoms, (iii) la date de naissance, (iv) la durée de la grossesse; b) concernant le père naturel ou l’autre parent, (i) le nom de famille à la naissance, (ii) les prénoms, (iii) la date de naissance.

4. Information in respect of the health care professional, if any, in attendance at the time of birth: (a) surname and given names; (b) designation of health care professional (physician, midwife, nurse, other); (c) mailing address.

5. Certification of adoptive parents: (a) signature of mother and date signed; (b) signature of father or other parent and date signed.

6. Certification of Registrar General and administrative information: (a) signature of Registrar General and date signed; (b) registration number assigned by the Registrar General.

Part 3 - Stillbirth Registration Statement

1. Information in respect of the stillborn child: (a) surname; (b) given names; (c) sex; (d) place of stillbirth; (e) weight of stillborn child in grams; (f) kind of birth (single or multiple) and, if a multiple birth, (i) the number of children born, (ii) the child’s birth order.

2. Information in respect of the parents: (a) in respect of the mother, (i) surname at mother’s birth, (ii) given names, (iii) date of birth, (iv) place of birth, (v) ethnicity (to be indicated as "optional"), (vi) duration of pregnancy in respect of the stillborn child whose stillbirth is to be registered, (vii) total number of previous live born children, (viii) total number of stillborn children, including previous still born children and the stillborn child whose stillbirth is to be registered, (ix) mailing address and telephone number; (b) in respect of the father or other parent, (i) surname at father or other parent’s birth, (ii) given names, (iii) date of birth, (iv) place of birth, (v) ethnicity (to be indicated as "optional"), (vi) mailing address and telephone number; (c) an indication of whether parents are legally married and particulars of the marriage (to be indicated as "optional").

3. Certification of parents:

(b) signature of father or other parent and date signed.

4. Information to be contained in medical certificate of stillbirth: (a) date of stillbirth; (b) medical cause of the stillbirth (foetal or maternal); (c) an indication of the type of delivery, whether labour induced and whether death occurred before or after labour; (d) in respect of the health care professional or coroner who completes the medical certificate, (i) surname and given names, (ii) designation as a health care professional (physician, midwife, nurse) or coroner, (iii) mailing address; (e) an indication of whether a post-mortem examination will be performed on the remains of the stillborn child; (f) an indication of whether further information relating to the cause of death will be available at a later date; (g) signature of health care professional or coroner and date signed.

5. Information in respect of the disposition of remains: (a) type of final disposition (burial, cremation, other); (b) date of disposition; (c) place of final disposition (name and address of cemetery, crematorium, other); (d) surname and given names of funeral planner in charge of remains; (e) mailing address of funeral planner.

6. Certification of Registrar General and administrative information: (a) signature of Registrar General and date signed; (b) registration number assigned by the Registrar General.

Part 4 - Marriage Registration Statement

1. Information in respect of each party to the marriage: (a) surname at time of marriage; (b) given names; (c) marital status at time of marriage (single, widowed, divorced); (d) date of birth; (e) place of birth; (f) mailing address and telephone number; (g) surname, given names and place of birth of each parent of the party; (h) ethnicity (to be indicated as "optional").

2. Information in respect of the marriage: (a) place of marriage (address of church or other location where marriage was solemnized or performed); (b) date of marriage.

3. Information in respect of each adult witness to the marriage:

4. Information in respect of the person who solemnized or performed the marriage: (a) surname; (b) given names; (c) designation (registered cleric, justice of the peace or marriage commissioner); (d) mailing address and telephone number.

5. Information in respect of marriage licence or certificate of publication of banns: (a) an indication of whether a marriage licence or certificate of publication of banns issued; (b) marriage licence number or copy of certificate of publication of banns, as the case may be.

6. Certification of marriage: (a) signature of parties to the marriage; (b) signature of witnesses to the marriage; (c) signature of person who solemnized or performed the marriage and date signed.

7. Certification of Registrar General and administrative information: (a) signature of Registrar General and date signed; (b) registration number assigned by the Registrar General.

Part 5 - Death Registration Statement

1. Information in respect of the deceased: (a) surname; (b) given names; (c) date of birth; (d) sex; (e) age at time of death (if under one year, indicated by months and days or if under one day, indicated by hours and minutes); (f) place of death; (g) place of birth; (h) marital status at time of death (single, common-law, married, widowed, divorced); (i) in respect of the spouse, if any, at time of death of the deceased, (i) surname at birth, (ii) given names; (j) usual place of residence at time of death; (k) occupation (at time of death or for majority of working life, as applicable); (l) ethnicity (to be indicated as "optional").

2. Information in respect of each parent of the deceased: (a) surname at parent’s birth;

(c) place of birth.

3. Information in respect of the person who completes the death registration statement and certification: (a) surname; (b) given names; (c) mailing address and telephone number; (d) relationship to the deceased; (e) signature and date signed; (f) an indication of whether the person consents to disclosure of information to the Canada Revenue Agency for the purpose of determining whether a person is or is not entitled to benefits provided under the Income Tax Act (Canada) or the Universal Child Care Benefit Act (Canada); (g) an indication of whether the person consents to disclosure of the deceased’s Social Insurance Number to any department or agency of the Government of Canada, including any branch, division or institution of the department or agency, responsible for administering the Social Insurance Register under the Department of Employment and Social Development Act (Canada), for the purpose of maintaining and verifying the accuracy of information in the Social Insurance Register.

4. Information to be contained in medical certificate of death: (a) date of death; (b) medical cause of death; (c) manner of death (natural, accident, suicide, homicide or undetermined); (d) place and circumstances of injury, if any; (e) in respect of the health care professional or coroner who completes the medical certificate, (i) surname and given names, (ii) designation of that person as a health care professional (physician, nurse) or coroner, (iii) mailing address; (f) an indication of whether a post-mortem examination will be performed on the remains of the deceased; (g) an indication of whether further information relating to the cause of death will be available at a later date; (h) an indication of whether alcohol or tobacco use was a contributing factor in death; (i) signature of health care professional or coroner and date signed.

5. Information in respect of the disposition of remains: (a) type of final disposition (burial, cremation, other); (b) date of disposition; (c) place of final disposition (name and address of cemetery, crematorium, other); (d) surname and given names of funeral planner in charge of remains; (e) mailing address of funeral planner.

6. Certification of Registrar General and administrative information: (a) signature of Registrar General and date signed; (b) registration number assigned by the Registrar General. Part 6 - Notice of Birth (in hospital)

(a) date of birth; (b) place of birth; (c) sex; (d) surname and given names, if known.

2. Information in respect of the mother: (a) surname at mother’s birth; (b) given names; (c) date of birth; (d) mailing address and telephone number.

3. Name of hospital where birth occurred or where child was

Part 7 - Notice of Birth (not in hospital)

1. Information in respect of the child: (a) date of birth; (b) place of birth; (c) sex; (d) surname and given names, if known.

2. Information in respect of the mother: (a) surname at mother’s birth; (b) given names; (c) date of birth; (d) mailing address and telephone number.

3. Information in respect of the health care professional, if (a) surname and given names; (b) designation of health care professional (physician, (c) mailing address; (d) signature and date signed.

Part 8 - Notice of Stillbirth

1. Information in respect of the stillborn child: (a) surname; (b) given names; (c) sex; (d) place of stillbirth; (e) date of stillbirth. Partie 6 - Avis de naissance (à l’hôpital)

a) la date de naissance; b) le lieu de naissance; c) le sexe; d) le nom et les prénoms, si connus.

2. Renseignements concernant la mère : a) le nom de famille à la naissance; b) les prénoms; c) la date de naissance; d) l’adresse postale et le numéro de téléphone.

3. Nom de l’hôpital où la naissance a eu lieu ou où l’enfant

Partie 7 - Avis de naissance (ailleurs qu’à l’hôpital)

1. Renseignements concernant l’enfant : a) la date de naissance; b) le lieu de naissance; c) le sexe; d) le nom de famille et les prénoms, si connus.

2. Renseignements concernant la mère : a) le nom de famille à la naissance; b) les prénoms; c) le lieu de naissance; d) l’adresse postale et le numéro de téléphone.

3. Renseignements concernant le professionnel de la santé a) le nom et les prénoms; b) la désignation du professionnel de la santé (médecin, c) l’adresse postale; d) la signature et la date de la signature.

Partie 8 - Avis de mortinaissance

1. Renseignements concernant l’enfant mort-né : a) le nom de famille; b) les prénoms; c) le sexe; d) le lieu de mortinaissance; e) la date de mortinaissance.

2. Information in respect of the mother: (a) surname at mother’s birth;

3. Name of hospital where stillbirth occurred or where stillborn child was brought shortly after stillbirth.

Part 9 - Notice of Death

1. Information in respect of the deceased: (a) surname; (b) given names; (c) date of birth; (d) sex; (e) place of death; (f) date of death.

2. Name of hospital where death occurred or where body of deceased was brought shortly after death.

3. Name and telephone number of a family member of the deceased, if available.

Part 10 - Birth Certificate

1. Additional information to be set out in a long form birth certificate: (a) in respect of the mother, (i) surname at mother’s birth, (ii) given names, (iii) place of birth; (b) in respect of the father or other parent, (i) surname at father’s or other parent’s birth, (ii) given names, (iii) place of birth.

Part 11 - Marriage Certificate

1. Additional information to be set out in a long form marriage certificate: (a) date of birth of both parties; (b) place of birth of both parties.

R-059-2017,s.6.

SCHEDULE B (subsection 7(2))

Oath (or Affirmation) of Secrecy

I, .............................................. , swear (or affirm) that I will not, without due authority, disclose or make known any matter that comes to my knowledge by reason of having access to the records or part of the records kept under the Vital Statistics Act of the Northwest Territories. So help me God. (omit last sentence for an affirmation)

Sworn (or Affirmed) before me

at ...................................... on (place)

........................................... (date)

........................................... ........................................... (signature of person administering oath or (signature of person taking oath or affirmation) affirmation)

SCHEDULE C (subsection 9(1))

Fees

1. Registration of birth, marriage or death received after the expiry of one year after the date of event (subsection 28(2), 52(2) or 64(2) of the Act) .................................................. $26

2. Issuing of birth certificate, marriage certificate or death certificate (subsection 80(1), 83(1) or 85(1) of the Act) (a) regular processing................................................................ $26 (b) expedited processing.............................................................. $38 (plus courier charges, if any).

3. Issuing of certified copy of original birth registration statement, marriage registration statement, death registration statement or stillbirth registration statement (subsection 40(2), section 81, 84, 86 or 87 of Act) (a) regular processing ............................................................... $39 (b) expedited processing.............................................................. $51 (plus courier charges, if any).

4. Issuing of certified copy of declaration filed with the Registrar General (subsection 12(1) of the Children’s Law Act).................................................. $39

5. Amendments: (a) to birth registration statement, marriage registration statement, death registration statement or stillbirth registration statement (subsection 16(2) of the Act)........................................................ $39 (b) to change or add given name on birth registration statement (subsection 34(2) of the Act) (i) if application received within 60 days of birth .................................. NIL (ii) if application received more than 60 days after birth ............................. $39 (c) to add parent or change surname on birth registration statement (subsection 37(2) of the Act) (i) if application received within 60 days of birth .................................. NIL (ii) if application received more than 60 days after birth ............................. $39 (d) to change designation of sex on a birth registration statement (subsection 42(1) of the Act)........................................................ $39

6. Issuing of reburial permit (subsection 69(2) of the Act).......................................... $26

7. Search of Vital Statistics Register (subsection 78(1) of the Act) ................................... $26

R-021-2025,s.5.