NOT FOR USE ON RECORDS FILED PRIOR TO JANUARY 1, 1916

68555 25M 9-88

For Original Record

STATE OF ILLINOIS

AFFIDAVIT AND CERTIFICATE OF CORRECTION

Concerning the record of:

birth

FULL NAME

whose stillbirth occurred

death

at

in the County of

, Illinois on the

day of

19

In keeping with the provisions of Paragraph 73-22 of the Vital Statistics Act, Paragraph 73-1 through 73-29, Chapter 111½, Illinois Revised Statutes, 1961, as amended, I hereby certify under oath that the following items appearing on the original certificate identified above are incorrect or missing and should be corrected as follows:

omitted

ITEM No.

was incorrectly given as

and SHOULD READ

omitted

ITEM No.

was incorrectly given as

and SHOULD READ

omitted

ITEM No.

was incorrectly given as

and SHOULD READ

omitted

ITEM No.

was incorrectly given as

and SHOULD READ

omitted

ITEM No.

was incorrectly given as

and SHOULD READ

omitted

ITEM No.

was incorrectly given as

and SHOULD READ

Address

Street & No.

Signed

City & State

Relationship

Subscribed and sworn to before me this

day of

19

Address

Street & No.

Signed

City & State

Title

Documents Accepted as Supporting Evidence

1

Date made

2

Date made

3

Date made

4

Date made

5

Date made

Accepted for filing on the

day of

19

By

Title

..................................................

VR-400

OFFICE OF VITAL RECORDS – ILLINOIS DEPARTMENT OF PUBLIC HEALTH – SPRINGFIELD 62761

Printed by the Authority of the State of Illinois