(FILL OUT THIS ABSTRACT EITHER BY TYPEWRITER OR BY HANDLETTERING IN PERAMENT BLACK OR BLUE BALCK INK)

ABSTRACT OF A RECORD

ABSTRACT MUST BE MADE BY A CLERK OF COUNTY COURT OR NOTARY PUBLIC OVER HIS SIGNATURE AND SEAL

This is a

record

(Bible, Family History, School Census, Employment, Etc.)

pertaining to

(Name of Individual)

The record is filed under No.

, Volume

,  Page

Dated

and is in the custody of

(Name)

(Address)

This record states the following concerning the person named above.

(Here copy the EXACT WORDING of the record which relates to (1) the name of the child, (2) the date of birth, (3) the place of birth, (4) the father's name, (5) the mother's maiden name.)

COMMENTS  ON  CHANGES  OR  ERASURES:

I hereby certify that I have examined the record above described; that it contains the entries above set forth; that there is apparently no erasure or amendment of the birth or other essential information except as explained above; and that the appearance of the paper and ink of said record indicates that the entries were made at least _______ years ago.

Date

Signed

(SEAL)

Title

Address

VR – 154e

State of Illinois – Department of Public Health – Bureau of Vital Records