Ill. Admin. Code tit. 77, pt. 500, app E, ILLUSTRATION B
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)
Ill. Admin. Code tit. 77, pt. 500, app E, ILLUSTRATION B