FORM C – AFFIDAVIT OF PARENT FOR A DELAYED REGISTRATION OF THE BIRTH OF

ON

Name

Month

Day

Year

AT

ILLINOIS

City and County

STATE OF

}

COUNTY OF

        I,

, of lawful age, being

duly sworn upon oath, depose and say:

        THAT I am the

of the person named above and that this child was born on

Father, Mother

at

Month

Day

Year

Street address or general location in the community

in

,

County, Illinois;

City, village, township or road district

AND FURTHER THAT the personal particulars of the child's parents are as follows:

Father's full name is

his color or race is

the year of his

birth was

and his birthplace was

City or county and state or country

Mother's MAIDEN name is

her color or race is

the year of her

birth was

and her birthplace was

City or county and state or country

AND FURTHER THAT this was a

birth and that this child was the

Single, twin, triplet

1st, 2nd, 3rd, 4th, etc.

child born alive to this mother and that the following children were born to her on or before the birthdate of this child at the places and dates stated:

NAME

SEX

DATE OF BIRTH

BIRTHPLACE

(month, day, year)

(city or county & state or country)

was

1)

,

male,

born

at

was

2)

,

male,

born

at

was

3)

,

male,

born

at

was

4)

,

male,

born

at

was

5)

,

male,

born

at

was

6)

,

male,

born

at

Signed

Address:

Subscribed and sworn to before me this

day of

19

at

Notary Public in and for the State of

(SEAL)

Address:

VR-154C

FORM FURNISHED BY THE DEPARTMENT OF VITAL RECORDS, ILLINOIS DEPARTMENT OF PUBLIC HEALTH