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



Section 500.APPENDIX B   Delayed Birth Records

 

Section 500.ILLUSTRATION C   Filing a Delayed Record of Birth After the Seventh Birthday)

 

FILING A DELAYED RECORD OF BIRTH AFTER THE SEVENTH BIRTHDAY

 

                These instructions apply only to, a living person, born in Illinois, whose birth record is not on file, and who has passed his or her 7th birthday.

 

PLEASE FOLLOW THE INSTRUCTIONS CAREFULLY

 

BIRTH PRIOR TO JANUARY 1, 1916 – Secure a written statement from the County Clerk that the birth is not on file.  A space for this statement is provided on the Birth Record form.  Proceed with the instructions below.

 

BIRTHS AFTER JANUARY 1, 1916 – Proceed with the instructions below.

 

IN ORDER TO ESTABLISH A DELAYED RECORD OF BIRTH

 

1.        Complete through line 7 on the Delayed Record of Birth Application – FORM VR 141.

 

2.        Sign and have notarized Line 8.  (See example below)

 

3.        If either of your parents are living, have one of them complete Form C, sign it, and have it notarized.  If not, have a brother, sister, aunt, uncle, or friend who has known you for at least 25 years, complete Form D, sign it and have it notarized.

 

4.        In addition to submitting the forms mentioned in item 3, you must submit one or more documents, created at least 5 years ago that prove your birthdate and birthplace.  Suggested documents are listed on the back of this sheet.

 

5.        The statutory fee for filing a Delayed Record of Birth is $15.00.  This fee entitles you to one certified copy of the birth record after it is accepted for filing by this office.

 

Application must be signed before a Notary Public.  The Notary will then complete the form with the date signed, his address, signature and raised seal.  If you do not know where to find a Notary Public, contact your bank, or check the yellow pages of your telephone directory.

 

STATE OF ILLINOIS

DELAYED RECORD OF BIRTH

 

ORIGINAL

DEPARTMENT OF PUBLIC HEALTH

STATE FILE NO.

 

 

(REGISTERED AFTER SEVENTH BIRTHDAY)

 

CHILD-NAME

FIRST

MIDDLE

LAST

DATE OF BIRTH (MONTH, DAY, YEAR)

1.

Mary

Jane

Smith

2.

July 4, 1875

If your name has been changed (except by marriage) enter the name you are now known by in this space.

SEX

3.

Mary Ellen Smith

4.

Female

CITY, TOWN, TWP. OR ROAD DISTRICT NO.

COUNTY

5a.

Chicago

 

5b.

Cook

MOTHER- MAIDEN NAME

FIRST

MIDDLE

LAST

AGE (AT TIME OF THIS BIRTH)

STATE OF BIRTH (IF NOT IN U.S.A. NAME  COUNTRY)

6a.

Betty

Lou

Brown

6b.

22

6c.

Illinois

FATHER - NAME

FIRST

MIDDLE

LAST

AGE (AT TIME OF THIS BIRTH)

STATE OF BIRTH (IF NOT IN U.S.A. NAME  COUNTRY)

7a.

James

 

Smith

7b.

23

7c.

Germany

8.

AFFIDAVIT:  I hereby declare upon oath that the above statements are true to the best of my knowledge and belief.

a.)  Signed

Mary Ellen Jones

b.)  Address

222 Fast Corner Street

 

(PRESENT LEGAL NAME OF REGISTRANT)

 

Chicago, Illinois 60000

(SEAL)

 

c.)  Submitted and sworn to before me this

2nd

day of

February

19

64

 

at

Chicago, Illinois

 

John Doe

 

 

(PLACE)

 

SIGNATURE OF COUNTY CLERK OR NOTARY

APPLICANT!  DO NOT WRITE BELOW THIS LINE

VR 154 (Rev.2/84)

 

SUGGESTED DOCUMENTS

(to prove date & place of birth – at least 5 years old)

 

HOSPITAL'S RECORD OF THE DELIVERY – Obtain from hospital of birth.

 

ATTENDING PHYSICIAN'S OR LICENSED MIDWIFE'S RECORD OF THE DELIVERY – Obtain from the physician, midwife, or present custodian of their records.

 

BAPTISMAL, CRADLE ROLL, OR OTHER CHURCH RECORD – Obtain from the present custodian of the church records, showing name and location of church, baptismal date and birth facts.

 

BIRTH ANNOUNCEMENT – Submit one which was sent to a relative or friend, showing the date it was mailed.

 

COPY OF LIFE INSURANCE OR BURIAL INSURANCE APPLICATION – Obtain from the insurance company showing name and address of company, policy number, date of issuance and birth facts.

 

FAMILY BIBLE RECORD – Submit only if entry is dated and was made at or near the time of birth. Give name and address of present custodian of the Bible.

 

HOSPITAL OR CLINIC ADMISSION RECORD – Obtain statement from hospital or clinic, showing location, date of admission, and applicant's birth facts.

 

SCHOOL ENROLLMENT OR SCHOOL CENSUS RECORD – Obtain from the county superintendent of schools or the city board of education where person entered school. (If in Chicago, write to the Chicago Board of Education, 228 North LaSalle, Chicago, Illinois 60601).

 

FEDERAL CENSUS REPORT – (preferably the first census taken after the person's birth) Obtain from Department of Commerce, Bureau of the Census, Pittsburg, Kansas  66762. Obtain blanks from county clerk or the Illinois Department of Public Health.

 

MARRIAGE RECORD – Secure a certified copy of the marriage license application and return (NOT the marriage certificate itself) from the county clerk of the county where the license was obtained.  (Information not on Cook County marriages).

 

VOTING REGISTRATION – By the present election commission of the area (NOT YOUR CARD).

 

SOCIAL SECURITY – Photocopy of APPLICATION for Social Security number – available FREE from the Social Security Administration, Baltimore, Maryland (NOT YOUR CARD).

 

MILITARY RECORD – From any branch of the United States Armed Services.

 

BIRTH CERTIFICATE OF A CHILD OF THE PERSON WHOSE BIRTH IS NOW BEING REGISTERED – Furnish names of children, and dates and places of birth, if born in Illinois after 1915: otherwise, FULL certified copy issued by official custodian of record.

 

ONLY ONE NOTARIZED AFFIDAVIT – may be accepted as one proof of the birth facts, when sufficient documents are not available to prove the birth facts as outlined above. The affidavit may be made by a relative, or a friend of 25 years, familiar with the birth facts. The person making the affidavit should sign IN INK his or her first and present last name and present address, BEFORE A NOTARY PUBLIC.

 

Submit the documents and completed record to:

 

Illinois Department of Public Health

Division of Vital Records

535 West Jefferson Street

Springfield, IL.  62761

 

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