Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 500 - ILLINOIS VITAL RECORDS CODE
Appendix E - Adoption Records
ILLUSTRATION H - Information Exchange Authorization Form
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 Information Exchange Authorization, 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.
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Given under my hand and notarial seal on |
_________________ |
, |
___________ |
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(insert date) |
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_________________________ |
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SIGNATURE OF NOTARY |
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Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097 |
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VR 161.7 (rev. 05/2000) |
Printed by Authority of the State of Illinois P.O.# 30M 02/00 |
