TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER e: VITAL RECORDS
PART 500 ILLINOIS VITAL RECORDS CODE
SECTION 500.APPENDIX C MARRIAGE APPLICATION AND RECORD



Section 500.APPENDIX C   Marriage Application and Record

 

 

STATE OF ILLINOIS

STATE FILE NUMBER

 

MARRIAGE APPLICATION AND RECORD

 

TYPE / PRINT

IN

PERMANENT

BLACK INK

County

License

Number

 

1. Groom –  Name

First

Middle

Last

 

 

2a. Residence – Street and Number or R.F.D.

2b. City

2c. County

2d. State

 

GROOM

3a. Date of Birth (Month, Day, Year)

3b. Age

3c.    Birthplace (State or          Foreign Country)

4. Social Security Number

5. Usual Occupation

Printed by the Authority of the State of Illinois

6a. Father – Name

6b. Address

6c. Birthplace (State or

      Foreign Country)

 

7a. Mother – Maiden Name

7b. Address

7c. Birthplace (State or

      Foreign Country)

 

8a. Bride  –  Name

First

Middle

Last

8b. Maiden Name (If Different)

 

9a. Residence – Street and Number or R.F.D.

9b. City

9c. County

9d. State

 

BRIDE

10a. Date of Birth (Month, Day, Year)

10b. Age

10c.  Birthplace (State or          Foreign Country)

11. Social Security Number

12. Usual Occupation

 

13a. Father – Name

13b. Address

13c.  Birthplace (State or          Foreign Country

 

14a. Mother – Maiden Name

14b. Address

14c.  Birthplace (State or          Foreign Country

 

15. If Parties Are Related To Each Other – Specify Relationship

16. This License Effective On –

 

 

WE HEREBY CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION IS TRUE TO THE BEST OF OUR KNOWLEDGE, THAT WE ARE FREE TO INTERMARRY UNDER THE LAWS OF THIS STATE AND THE LAWS OF THE JURISDICTION WHERE WE RESIDE AND WE ARE THE IDENTICAL PERSONS NAMED IN THE ACCOMPANYING PHYSICIAN'S CERTIFICATES.

AFFIDAVIT

17. Groom (Sign Full Name)

18. Bride (Sign Full Name)

 

19. Subscribed and Sworn To Before Me On:

20. Signature of County Clerk

By

Deputy

 

21. Date of Marriage (Month, Day, Year)

22. Place of Marriage (City, Vill., or Town. If Rural, Give Twp. Name or Road Dist.)

23. Type of Ceremony       (Religious or Civil)  (Specify)

MARRIAGE

RECORD

24. Name of Officiant

25. Title

 

26. Date Recorded (Month, Day, Year)

27. Signature of County Clerk

By

Deputy

 

VR 600 (1989)

ILLINOIS DEPARTMENT OF PUBLIC HEALTH – OFFICE OF VITAL RECORDS

(BASED ON 1989 U.S. STANDARD FORM)

 

 

 

 

 

 

 

 

 

 

 

INFORMATION FOR STATISTICAL PURPOSES ONLY

 

Race

Education (Specify Highest Grade Completed)

Number of This Marriage

If Previously Married – Last Marriage Ended by Death, Dissolution or Invalidity of Marriage

 

SPECIFY (e.g. WHITE, BLACK, AMERICAN INDIAN, ETC.)

ELEMENTARY OR SECONDARY (0-12)

COLLEGE (1-4 OR 5 +)

FIRST-SECOND ETC. (SPECIFY)

SPECIFY HOW

SPECIFY WHEN (MONTH, DAY, YEAR)

SPECIFY WHERE-COUNTY & STATE

GROOM

28.

29.

 

30a.

30b.

30c.

30d.

 

 

BRIDE

31.

32.

 

33a.

33b.

33c.

33d.

 

 

34.      Of Hispanic Origin?

 

34a.

□  No

□  Yes

 

34b.

  No

  Yes

 

           (Specify No or Yes – If yes, specify

GROOM

 

BRIDE

 

 

           Cuban, Mexican, Puerto Rican, etc.)

 

Specify:

 

Specify:

IL 482-0010

 


 

AFFIDAVIT OF CONSENT OF PARENT OR GUARDIAN FOR MARRIAGE OF MINOR

 

STATE OF ILLINOIS                   SS.

COUNTY______________________

 

_________________________________________________   AND   _________________________________________________

 

BEING DULY SWORN, DEPOSES AND SAYS THAT THEY ARE THE PARENTS OR GUARDIAN OF_______________________,

 

A MINOR, AND GIVE THEIR CONSENT TO THE MARRIAGE OF SAID MINOR TO___________________________________, AND

 

AFFIANTS FURTHER SAY THAT THE SAID MINOR WAS BORN__________________, 19____.

 

 

 

SIGNATURE OF FATHER OR GUARDIAN

 

SIGNATURE OF MOTHER OR GUARDIAN

 

 

 

SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF ____________________________, 19______.

 

 

 

 

SIGNATURE OF COUNTY CLERK OR NOTARY

 

 

 

 

 

 

STATE OF ILLINOIS                   SS.

COUNTY______________________

 

_________________________________________________ AND __________________________________________________

 

BEING DULY SWORN, DEPOSES AND SAYS THAT THEY ARE THE PARENTS OR GUARDIAN OF_______________________,

 

A MINOR, AND GIVE THEIR CONSENT TO THE MARRIAGE OF SAID MINOR TO_________________________________, AND

 

AFFIANTS FURTHER SAY THAT THE SAID MINOR WAS BORN__________________, 19____.

 

 

 

 

SIGNATURE OF FATHER OR GUARDIAN

 

SIGNATURE OF MOTHER OR GUARDIAN

 

 

 

SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF ____________________________, 19______.

 

 

 

 

SIGNATURE OF COUNTY CLERK OR NOTARY

 

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