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



Section 500.APPENDIX H Affidavits

 

Section 500.ILLUSTRATION C Affidavit and Certificate of Correction

 

 

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 111, 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

 

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