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 C   Information Concerning Parents

 

Division of Vital Records

605 W. Jefferson St.

Springfield, IL  62702

FULL NAME OF CHILD

 

 

 

 

 

 

 

 

INFORMATION CONCERNING PARENTS

 

FATHER

 

MOTHER

Full

Name

 

 

Full

Maiden Name

 

Residence at the time this child was born

 

Residence at the time this child was born

(if rural, give township or road district)

 

(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

 

 

 

 

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.

DO NOT COUNT THIS CHILD.

 

(a)     Number

 

(b)    Number BORN alive

 

(c)     Number

 

still living

 

but now dead

 

born dead

 

 

 

SIGNATURE:

 

DATE:

 

 

VR168.1 (2/88)

 

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