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 K   Surrendered Person Registration Identification Form

 


Illinois Department of Public Health

SURRENDERED PERSON REGISTRATION IDENTIFICATION

(Enter all known information.)

 

I,

 

state the following:

         (present name)

(first)

(middle)

(last)

Surrendered person's

birth name (if known)

 

 

(first)

(middle)

(last)

Date of birth

 

Sex

 

Race

 

 

City and state of birth

 

 

Name of

birth mother

 

Race

 

 

   (if known)

(first)

(middle)

(maiden)

(last)

Name of

birth father

 

Race

 

 

   (if known)

(first)

(middle)

(last)

I was surrendered for adoption to

 

 

 

(name of agency)

City and state of agency

 

Date

 

 

 

(approximate)

Other identifying information

 

 

 

 

 

 

 

 

 

Name of

guardian father 

 

Race

 

 

   (if applicable

(first)

(middle)

(last)

Maiden name of

guardian mother 

 

Race

 

 

   (if applicable)

(first)

(middle)

(maiden)

(last)

 

Provide name(s) at birth and ages of siblings(s) having a common birth parent with surrendered person (if known). If more than one sibling, please give information requested below on reverse side of this form.

 

 

 

(first)

(middle)

(last)

Date of birth

 

Sex

 

Race

 

 

 

(or approximate age)

 

City and state of birth

 

 

Name(s) of common

birth parent(s)

 

Race

 

 

 

(first)

(middle)

(maiden)

(last)

 

 

Race

 

 

 

(first)

(middle)

(last)

(Please note that (i) you must be at least 21 to register and (ii) if you were not born  in Illinois, then you must submit a certified copy of your birth certificate.)

 

 

 

 

(signature of surrendered person)

 

 

 

(date)

 

(printed or typed name of surrendered person)

 

Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL   62702-5097

VR 161.3 (rev. 05/2000)                                                                     Printed by Authority of the State of Illinois P.O. # 30M 02/00

 

(Source:  Amended at 24 Ill. Reg. 11882, effective July 26, 2000)