Ill. Admin. Code tit. 77, pt. 500, app E, ILLUSTRATION K
Current through Register Vol. 48, No. 49, December 6, 2024
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(signature of surrendered person) | ||
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(date) | (printed or typed name of surrendered person) | |
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097
VR 161.3 (rev. 05/2000)Printed by Authority of the State of Illinois P.O. # 30M 02/00
Ill. Admin. Code tit. 77, pt. 500, app E, ILLUSTRATION K