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



Section 500.APPENDIX E   Adoption Records

 

Section 500.ILLUSTRATION A   Certificate of Adoption

 

STATE OF ILLINOIS

CERTIFICATE OF ADOPTION

(See reverse side for excerpts from statutes and other instructions)

PERSONAL DATA BASED ON ADOPTION NEEDED TO PREPARE THE NEW BIRTH CERTIFICATE

CHILD

1.

CHILD'S NEW NAME

(First)

(Middle)

(Last)

 

 

 

FATHER

2.

Father's

(First)

(Middle)

(Last)

3.  Father's Birth Date

 

 

Full

Name

 

 

4.

Father's

(State or foreign country)

5.  Color or Race

6a.  Usual Occupation

6b.  Kind of Business or Industry

 

Birth

Place

 

MOTHER

7.

Mother's

(First)

(Middle)

(Last)

8.  Mother's Birth Date

 

Maiden

Name

 

9.

Mother's

(State or foreign country)

10.  Color or Race

11.  Mother's Usual Residence (City, Town or Twsp. County & State)

 

Birth

 

 

 

 

Place

 

 

 

 

12.

How many OLDER children of this Mother

a.  Are now living?

b.  Are now dead?

c.  Were born dead?

 

 

(including adopted ones).

 

 

13.

A new certificate of birth

  is

  is not

to be prepared and filed.

 

 

 

VERIFICA-TION OF ABOVE DATA

14.

Signature of Parents Verifying above Personal Data

15.  Present Complete Mailing Address of Adoptive Parents

 

 

 

 

ATTORNEY

16.

Name of Attorney and Law Firm

17.  Attorney's Mailing Address

 

 

 

 

 

 

PERSONAL DATA NEEDED TO IDENTIFY ORIGINAL BIRTH CERTIFICATE (Which will be removed to a Sealed File)

18.

Child's

(First)

(Middle)

(Last)

19.  State Birth Certificate Number if Known

 

Name

 

at Birth

 

20. 

Sex

21.

Date

(Mo)

(Day)

(Yr.)

22.  Place of Birth

a. State

b. County

c. City, Village or Twsp.

d. Hospital

of

Birth

23.

Maiden Name

(First)

(Middle)

(Last)

 

 

of Natural

 

 

Mother

 

24.

Full Name

(First)

(Middle)

(Lasts)

 

of Natural

 

 

Father

 

CERTFICATION OF  CLERK  OF COURT

25.

STATE OF ILLINOIS

Case Number

 

 

CIRCUIT COURT OF

COUNTY

Date of Decree

 

I hereby certify that the child identified at item 18 was adopted by the parent(s) named at items 2 and 7, and is now to bear the name shown at item number 1, as set forth in the Decree of Adoption.

 

COURT

SEAL

 

Signed

, Clerk

 

 

Date Signed

at

, Illinois

 

 

Vr 160 (1969r)  (Send this Certificate of Adoption to: State Registrar of Vital Records, Illinois Department of Public Health, Springfield, Illinois  62706)

 

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