Ill. Admin. Code tit. 77, pt. 500, app E, ILLUSTRATION I
I, a Notary Public, in and for the said county, in the state aforesaid, do hereby certify that _______________ personally known to me to be the same person whose name is subscribed to the foregoing Denial of Information Exchange, appeared before me in person and acknowledged that he/she signed such authorization as his/her free and voluntary act and that the statements in such authorization are true.
Given under my hand and notarial seal on | , | |||
___________________________________ (insert date) | ||||
____________________________________ SIGNATURE OF NOTARY | ||||
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR 161.8 (rev.04/2000)Printed by Authority of the State of Illinois PO# 30M 02/00
Ill. Admin. Code tit. 77, pt. 500, app E, ILLUSTRATION I