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:

Father’s name:

Mother’s maiden  name:

other corrections needed:

Please mail correction forms to:

Name:

Address:

Date:

My relationship to deceased:

VR-401.2 REV. 6/78