Ill. Admin. Code tit. 77, pt. 500, app E, ILLUSTRATION C
Division of Vital Records
605 W. Jefferson St.
Springfield, IL 62702
FULL NAME OF CHILD
_______________________
_______________________
INFORMATION CONCERNING PARENTS
FATHER | MOTHER | ||||||||||||||||
Full Name | _______________________ | Full Maiden Name | _______________________ | ||||||||||||||
Residence at the time this child was born | Residence at the time this child was born | ||||||||||||||||
(if rural, give township or road district) | (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 | _______________________ | ||||||||||||||
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.
DO NOT COUNT THIS CHILD.
(a) Number | __________ | (b) Number BORN alive | __________ | (c) Number | __________ | ||||
still living | __________ | but now dead | __________ | born dead | __________ | ||||
SIGNATURE: | ______________________ | |
DATE: | _______________________ | |
VR168.1 (2/88)
Ill. Admin. Code tit. 77, pt. 500, app E, ILLUSTRATION C