Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 500 - ILLINOIS VITAL RECORDS CODE
Appendix A - Birth Records
ILLUSTRATION C - 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