Section 500.APPENDIX B   Delayed Birth Records

THIS IS A PERMAMENT RECORD

•USE TYPEWRITER WITH BLACK RIBBON OR PRINT WITH PEN USING BLACK INK

•ALL SIGNATURES MUST BE HANDWRITTEN IN PEN AND INK

This Delayed Record of Birth must be executed in accordance with the provisions of Paragraph 73-14 of the Vital Records Act

(Paragraphs 73-1 through 73-29, Chapter 111 ½, Illinois Revised Statutes, as amended) and with the rules and instructions of the

                                                         Illinois Department of Public Health. 

                                                                 This record shall be presented for filing to the State Registrar of Vital Records at Springfield.

When accepted and filed an exact copy will be furnished the county clerk of the county in which the birth occurred.

I certify that a diligent search of the official birth records was made and that no prior certificate was found for this registrant.

I certify that a diligent search of the official birth records was made and that no prior certificate was found for this registrant.

Signed ____________________________________________________

                                   Date _______________________________                                                                                                                                                                                                                                                                                                                                                                  Title______________________________________________________

STATE OF ILLINOIS

DEPARTMENT OF PUBLIC HEALTH

ORIGINAL

DELAYED RECORD OF BIRTH

STATE FILE NO.

(REGISTERED AFTER SEVENTH BIRTHDAY)

CHILD-NAME

FIRST

MIDDLE

LAST

DATE OF BIRTH (MONTH, DAY, YEAR)

1.

2.

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

SEX

3.

4.

CITY, TOWN, TWP, OR ROAD DISTRICT NO.

COUNTY

5a.

5b.

MOTHER-MAIDEN NAME

FIRST

MIDDLE

LAST

AGE (AT TIME OF THIS BIRTH)

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

6a.

6b.

6c.

FATHER-NAME

FIRST

MIDDLE

LAST

AGE (AT TIME OF THIS BIRTH)

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

7a.

7b.

7c.

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

b.)

Address

a.) Signed

(PRESENT LEGAL NAME OF REGISTRANT)

(SEAL)

c)

Subscribed and sworn to before me this

day of

19

at

(PLACE)

SIGNATURE OF COUNTY CLERK OR NOTARY

APPLICANT! DO NOT WRITE BELOW THIS LINE

KIND OF DOCUMENT AND DATE MADE

INFORMATION GIVEN IN DOCUMENT AS TO BIRTH DATE, BIRTHPLACE, AND PARENTS

ASBSTRACT OF SUPPORTING EVIDENCE

DOCUMENT

No. 1

Age or birth date:

Birthplace:

Father:

Mother:

DOCUMENT

No. 2

Age or birth date:

Birthplace:

Father:

Mother:

DOCUMENT

No. 3

Age or birth date:

Birthplace:

Father:

Mother:

DOCUMENT

No. 4

Age or birth date:

Birthplace:

Father:

Mother:

ACCEPTED AND FILED AT SPRINGFIELD FOR THE STATE REGISTRAR OF VITAL RECORDS

by

Deputy State Registrar, on

,

19

This record is valid only if it has been accepted by and filed with the State Registrar of Vital Records at Springfield, Illinois.

ILLINOIS DEPARTMENT OF PUBLIC HEALTH – OFFICE OF VITAL RECORDS