§500.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

VR-162Z  (8/71r)

 

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