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 B   Information Concerning Adoptive Parents

 

DEPARTMENT OF PUBLIC HEALTH

DIVISION OF VITAL RECORDS

605 W. JEFFERSON ST.

SPRINGFIELD, IL  62702-5097

 

RE:       ADOPTION OF (Child's name by adoption):

 

_______________________________________________________________

 

_______________________________________________________________

 

 

INFORMATION CONCERNING ADOPTIVE PARENTS

(Information should be given as existed when child was born)

 

ADOPTIVE FATHER

 

ADOPTIVE MOTHER

Full

Name

 

 

Full

Maiden Name

 

Residence at the time this child was born

(if rural, give township or road district)

 

Residence at the time this child was born

(if rural, give township or road district)

 

 

 

Street

 

Street

 

 

 

City or Place             &           State or Country

 

City or Place              &           State or Country

Color or Race

 

 

Color or Race

 

Date of Birth

 

 

Date of Birth

 

Place of Birth

 

 

Place of Birth

 

Social Security #

 

 

Social Security #

 

Occupation (at time this child was born)

 

Occupation (at time this child was born)

 

 

 

 

List below all OTHER children of this mother who were born BEFORE this child was born, counting children BORN to her and other children ADOPTED by her.            DO NOT COUNT THIS CHILD.

 

(a)  Number still living  ___     (b)  Number BORN alive but now dead ___    (c)  Number born dead ___

 

 

(signature of one adoptive parent)

Date:

 

VR 168 (3/91)

 

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