Ill. Admin. Code tit. 77, pt. 500, app A, ILLUSTRATION D
Current through Register Vol. 49, No. 2, January 10, 2025
STATE OF ILLINOIS
CERTIFICATE OF BIRTH - FOUNDLING CHILD
File No. ______________________
NAME GIVEN CHILD BY CUSTODIAN: | ||||||||
PLACE CHILD WAS FOUND: | (CITY, VILLAGE, TOWNSHIP OR ROAD DISTRICT) | (COUNTY) | ||||||
DATE CHILD WAS FOUND: | (MONTH) | (DAY) | (YEAR) | SEX | RACE | APPROXIMATED AGE: | ||
NAME OF CUSTODIAN: | (PERSON OR INSTITUTION) | |||||||
MAILING ADDRESS OF CUSTODIAN: | ||||||||
CHILD FOUND BY: | ||||||||
MAILING ADDRESS OF FINDER: | ||||||||
REPORTED TO REGISTRAR ON: | (SIGNED) | LOCAL REGISTRAR | ||||||
ILLINOIS DEPARTMENT OF PUBLIC HEALTH - DIVISION OF VITAL RECORDS
VR 102 (2/79)
Ill. Admin. Code tit. 77, pt. 500, app A, ILLUSTRATION D