Ill. Admin. Code tit. 77, pt. 500, app A, ILLUSTRATION C

Current through Register Vol. 49, No. 2, January 10, 2025

Record of a Foreign Birth

STATE OF ILLINOIS RECORD OF A FOREIGN BIRTH

(ORIGINAL) STATE FILE NO. Z -

1. PLACE OF BIRTH:

(CITY)

(COUNTRY)

2. NAME OF CHILD:

3. DATE OF BIRTH:

(MONTH)

(DAY)

(YEAR)

4. SEX

5. FATHER'S FULL NAME:

6. FATHER'S BIRTH DATE:

(MONTH)

(DAY)

(YEAR)

7. FATHER'S BIRTHPLACE:

(CITY OR COUNTY)

(STATE OR COUNTRY)

8. MOTHER'S MAIDEN NAME:

9. MOTHER'S BIRTH DATE:

(MONTH)

(DAY)

(YEAR)

10. MOTHER'S BIRTHPLACE:

(CITY OR COUNTY)

(STATE OR COUNTRY)

OFFICE OF VITAL RECORDS - ILLINOIS DEPARTMENT OF PUBLIC HEALTH - SPRINGFIELD 62761

I HEREBY CERTIFY that this record is the original certificate of birth as established under the provisions of the Illinois Vital Records Act.

Date Filed

State Registrar

Springfield, Illinois

By _______________________

Deputy State Registrar

KIND OF DOCUMENT AND DATE MADE

BIRTH FACTS ESTABLISHED

VR-162Z (8/71r)

Ill. Admin. Code tit. 77, pt. 500, app A, ILLUSTRATION C

Added at 15 Ill. Reg. 11706, effective August 1, 1991