Section 500.APPENDIX E Adoption Records

Section 500.ILLUSTRATION B Information Concerning Adoptive Parents

DEPARTMENT OF PUBLIC HEALTH

DIVISION OF VITAL RECORDS

605 W. JEFFERSON ST.

SPRINGFIELD, IL 62702-5097

RE: ADOPTION OF (Child's name by adoption):

_______________________________________________________________

INFORMATION CONCERNING ADOPTIVE PARENTS

(Information should be given as existed when child was born)

ADOPTIVE FATHER					ADOPTIVE MOTHER
Full Name					Full Maiden Name
Residence at the time this child was born (if rural, give township or road district)					Residence at the time this child was born (if rural, give township or road district)

Street					Street

City or Place & State or Country					City or Place & State or Country
Color or Race					Color or Race
Date of Birth					Date of Birth
Place of Birth					Place of Birth
Social Security #					Social Security #
Occupation (at time this child was born)					Occupation (at time this child was born)

List below all OTHER children of this mother who were born BEFORE this child was born, counting children BORN to her and other children ADOPTED by her. DO NOT COUNT THIS CHILD.

(a) Number still living ___ (b) Number BORN alive but now dead ___ (c) Number born dead ___


(signature of one adoptive parent)
Date:

VR 168 (3/91)

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