§500.ILLUSTRATION A. Certificate of Live Birth

MATCHING DC

STATE OF ILLINOIS

CHILD'S BIRTH NUMBER

TYPE/PRINT IN

REGISTRATION

112-

PERMANENT

DISTRICT NO.

CERTIFICATE OF LIVE BIRTH

BLACK INK

REGISTERED

INSTRUCTIONS

NUMBER

SEE

CHILD'S NAME        FIRST             MIDDLE                 LAST

DATE OF BIRTH  (MONTH DAY YEAR)

TIME OF BIRTH

HANDBOOK

1.

2.

3.

M

CHILD

SEX

CHILD'S BLOOD TYPE

CITY, TOWN, TWP., ROAD DIST. NO. OR LOCATION OF BIRTH

COUNTY OF BIRTH

4.

5.

6.

7.

PLACE OF BIRTH

FACILITY NAME (IF NOT INSTITUTION, GIVE STREET AND  NUMBER

□ HOSPITAL

□  RESIDENCE

8.  OTHER (SPECIFY)

9.

I CERTIFY  THAT THIS CHILD WAS BORN ALIVE AT THE

DATE SIGNED  (MONTH,  DAY,   YEAR)

ATTENDANT'S NAME AND TITLE (IF OTHER THAN CERTIFIER)  (TYPE PRINT)

PLACE AND TIME AND ON THE DATE STATED:

10b

NAME

SIGNATURE

ILLINOIS LICENSE NUMBER

□    M.D.

□    D.O.

CERTIFIER ATTENDANT

10a. ►

10c

11.  OTHER (SPECIFY) ____________________________________________________

CERTIFIER'S NAME AND TITLE (TYPE PRINT)

ATTENDANTS MAILING ADDRESS (STREET AND NUMBER OR RURAL ROUTE NUMBER, CITY OR TOWN, STATE, ZIP CODE)

NAME  _________________________________________

□  M.D.

□  D.O

□  HOSPITAL ADMINISTRATOR

12.  OTHER (SPECIFY)  ___________________________________

13.

LOCAL REGISTRAR'S

DATE FILED BY LOCAL REGISTRAR      (MONTH,  DAY,  YEAR)

14.  SIGNATURE►

15.

MOTHER'S MAIDEN NAME      (FIRST,  MIDDLE,  LAST)

DATE OF BIRTH (MONTH ,  DAY ,   YEAR)

BIRTHPLACE (STATE OR FOREIGN COUNTRY)

16.

17.

18.

RESIDENCE-STREET AND NUMBER

CITY, TOWN, TWP., OR ROAD DIST. NO.

INSIDE CITY (YES  /  NO)

MOTHER

19a.

19b.

19c.

COUNTY

STATE

MOTHER'S MAILING ADDRESS (IF SAME AS RESIDENCE, ENTER ZIP CODE ONLY)

19d.

19e.

19f.

FATHER

FATHER'S NAME   (FIRST, MIDDLE, LAST)

DATE OF BIRTH (MONTH, DAY, YEAR)

BIRTHPLACE (STATE OR FOREIGN COUNTRY)

20.

21.

22.

INFORMANT

23.  I CERTIFY THAT THE PERSONAL INFORMATION PROVIDED ON THIS CERTIFICATE IS CORRECT TO THE BEST OF MY KNWOLEDGE AND BELIEF

23a.  MOTHER'S SIGNATURE ►

23b. FATHER'S SIGNATURE►

 

(Source:  Added at 15 Ill. Reg. 11706, effective August 1, 1991)