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



Section 500.APPENDIX F†† Death Records

 

Section 500.ILLUSTRATION F†† Application for Correction of a Death Certificate

 

APPLICATION FOR CORRECTION OF A DEATH CERTIFICATE

 

 

 

MAIL TO:

ILLINOIS DEPARTMENT OF PUBLIC HEALTH

 

 

OFFICE OF VITAL RECORDS

 

 

535 WEST JEFFERSON

 

 

SPRINGFIELD, ILLINOIS 62761

 

PLEASE SEND ME FORMS AND INSTRUCTION FOR CORRECTING THIS DEATH CERTIFICATE:

 

Full name of deceased:

 

 

 

Registered Number:

 

 

Date of death:

 

 

 

 

month

day

year

State file number:

 

 

 

 

Place of death:

 

 

 

 

 

 

 

hospital

 

county

 

city, village or township

 

FILL IN ONLY ITEMS TO BE CORRECTED

 

incorrect information now on certificate

 

should be corrected to read:

 

Name of Deceased:

 

 

 

 

Date of death:

 

 

 

 

Usual residence:

 

 

 

 

 

state

 

 

 

 

 

 

 

county

 

city, village or township

 

 

 

 

 

Married, never married, widowed, or divorced:

 

 

 

 

Birth date and age:

 

 

 

 

 

 

 

 

 

birth date

 

age

 

 

 

 

 

Birthplace:

 

 

 

 

Fatherís name:

 

 

 

 

Motherís maiden† name:

 

 

 

 

other corrections needed:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please mail correction forms to:

Name:

 

 

 

Address:

 

 

Date:

 

 

 

 

 

My relationship to deceased:

 

 

VR-401.2 REV. 6/78

 

 

 

 

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