For more than two years, Orietta Surace has been locked in a nightmarish bureaucratic battle over a single word.
Her circumstances were already tragic when she contacted the Registry of Births, Deaths and Marriages.
In 2015 Ms Surace gave birth to twin boys, 3½ months premature.
After 4½ months in an intensive care unit, one of her sons, Aurelius, died.
"He fought for a long time," Ms Surace says. "His lungs weren't strong enough."
Ms Surace just wanted official documents that accurately honoured her son's brief life – a birth certificate marking Aurelius' birth and a death certificate for when he died.
But when she received a birth certificate from the registry, Ms Surace and her husband Scott were horrified to find that it was marked with the word "deceased".
"I feel that a birth certificate is not just a legal document, Ms Surace says.
"It's recognition that someone was born alive and a valuable member of Victorian society."
She has made dozens of phone calls to the registry, waited on hold and written letters to get accurate birth and death certificates.
Instead they received documents with grammatical errors and names spelt incorrectly.
She has since received one birth certificate that is not marked "deceased" but Ms Surace says the registry told her that one was sent in error and has so far refused to send another identical copy.
Ms Surace acknowledges she missed the due date to fill out her sons' birth certificates because of the stress of their premature birth.
That has complicated her dealings with Births, Deaths and Marriages.
People who have died have their birth certificates marked "deceased" by the registry to guard against identity fraud.
But Ms Surace argues that is an "archaic" way of counteracting deception in the digital age.
Her experience with the registry sparked an investigation by the Victorian Ombudsman.
In January the Ombudsman issued a scathing report that found Births, Deaths and Marriages was understaffed, had poor record keeping and substandard complaints handling.
At the time, Ombudsman Deborah Glass said her office had received an increasing number of complaints about the registry.
Her report made a set of recommendations to improve the registry's performance, including developing a policy to use discretion about marking birth certificates "deceased".
A spokeswoman for Births, Deaths and Marriages said the registry had accepted all of the Ombudsman's recommendations and was working to improve its customer service.
"Births, Deaths and Marriages has taken action to put new systems and processes in place, including customer service training and a centralised complaints management system," she said.
But shadow attorney-general John Pesutto said Ms Surace's treatment by Births, Deaths and Marriages was "appalling".
"All of us would sincerely hope that were we to suffer such unspeakable anguish and trauma, we would not have to endure the bureaucratically heartless treatment Ms Surace experienced," he said.
Ms Surace's surviving son is now healthy and doing well but she has promised to keep fighting until she gets the documents she believes respect Aurelius' life.
"I don't want other parents to have to go through that again."
