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 F Application for Correction of a Birth Certificate

 

APPLICATION FOR CORRECTION OF A BIRTH CERTIFICATE

 

MAIL TO: Illinois Department of Public Health

Office of Vital Records

605 West Jefferson

Springfield, Illinois 62761

 

I wish to have errors corrected on the birth certificate identified as follows:

 

FULL NAME

OF CHILD:

 

 

PLACE

 

 

OF BIRTH:

 

HOSPITAL

COUNTY

CITY, VILLAGE, TOWNSHIP

 

DATE

REGISTERED

STATE FILE

OF BIRTH:

 

NUMBER

 

NUMBER

 

MONTH DAY YEAR

 

 

 

MOTHER'S

MAIDEN NAME:

 

 

FATHER'S NAME AS

 

 

LISTED ON BIRTH RECORD:

 

 

Please give us the INCORRECT and CORRECT information below:

INCORRECT INFORMATION

 

CORRECT INFORMATION

 

 

SHOULD READ

 

PRINT

 

PRINT

 

 

SHOULD READ

 

PRINT

 

PRINT

 

 

SHOULD READ

 

PRINT

 

PRINT

 

 

SHOULD READ

 

PRINT

 

PRINT

 

 

SHOULD READ

 

PRINT

 

PRINT

 

ADDITIONAL COMMENTS:

 

 

 

 

Please mail correction forms to:

WRITTEN SIGNATURE:

 

ADDRESS:

 

 

 

 

DATE:

 

MY RELATIONSHIP TO CHILD:

 

 

VR 401.1 REV. 6/75

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