Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 500 - ILLINOIS VITAL RECORDS CODE
Appendix I - Subregistrar's Appointment Blank

SUBREGISTRAR'S APPOINTMENT BLANK

I,

_________________________________________________

, Local Registrar of Registration District

No.

_____________________

County, Illinois, hereby request the State Registrar

of Vital Records to approve my appointment of the individual listed below as Subregistrar of Subregistration District No. ___________ , effective ______________ ,19 ______ .

Miss

Mrs.

Mr.

___________________________________

__________________________

(Name of Subregistrar)

(Local Title, if any, i.e., City Clerk)

Subregistration Office Address

___________________________________

______________________________

, Illinois

_______

(Zip Code)

Telephone Numbers: Office

_________

Residence

_________

Area Code

_____

The area in which I authorize this Subregistrar to serve is:

Anywhere within my Local Registration District.

Restricted to these areas:

______________________________________

___________________________________________________________________

Signed:

_________________

, Local Registrar___

Address:

______________________________

Dated:

_______

, 19

____

_________

, Illinois

______

(Zip Code)

APPROVED this

____

day of

____

, 19

____

____________________________________

, M.D.

Director, Illinois Department of Public Health; and State Registrar of Vital Records, Springfield, Illinois

NOTE:

Local Registrar should fill in and submit this form in triplicate to the Office of Vital Records, Illinois Department of Public Health, Springfield, Illinois, 62761. If the appointment is approved, the Department will retain one copy and return two to the Local Registrar, one for his files and one for the Subregistrar. An engraved certificate will also be sent the Local Registrar to present to the Subregistrar.

VR 303 (2/75)