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 F Affidavit in Support of an Application for a Delayed Registration of Birth (Continued)

 

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

 

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