TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER e: VITAL RECORDS
PART 500 ILLINOIS VITAL RECORDS CODE
SECTION 500.APPENDIX A BIRTH RECORDS



Section 500.APPENDIX A Birth Records

 

Section 500.ILLUSTRATION C Record of a Foreign Birth

 

STATE OF ILLINOIS

 

RECORD OF A FOREIGN BIRTH

(ORIGINAL)

STATE FILE NO.

Z

 

1. PLACE OF BIRTH:

(CITY)

(COUNTRY)

2. NAME OF CHILD:

3. DATE OF BIRTH:

(MONTH)

(DAY)

(YEAR)

4. SEX

5. FATHER'S FULL NAME:

6. FATHER'S

BIRTH DATE:

(MONTH)

(DAY)

(YEAR)

7. FATHER'S

BIRTHPLACE:

(CITY OR COUNTY)

(STATE OR COUNTRY)

8. MOTHER'S MAIDEN NAME:

9. MOTHER'S

BIRTH DATE:

(MONTH)

(DAY)

(YEAR)

10. MOTHER'S

BIRTHPLACE:

(CITY OR COUNTY)

(STATE OR COUNTRY)

 

OFFICE OF VITAL RECORDS ILLINOIS DEPARTMENT OF PUBLIC HEALTH SPRINGFIELD 62761

 

I HEREBY CERTIFY that this record is the original certificate of birth as established under the provisions of the Illinois Vital Records Act.

 

Date Filed

State Registrar

Springfield, Illinois

By ________________________________________

Deputy State Registrar

KIND OF DOCUMENT AND DATE MADE

BIRTH FACTS ESTABLISHED

 

 

 

 

 

 

 

 

 

 

VR-162Z (8/71r)

 

(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)