§500.ILLUSTRATION D. Certificate of Birth – Foundling Child

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STATE OF ILLINOIS

CERTIFICATE OF BIRTH – FOUNDLING CHILD

File No. ______________________

NAME GIVEN CHILD BY CUSTODIAN:
PLACE CHILD WAS FOUND:	(CITY, VILLAGE, TOWNSHIP OR ROAD DISTRICT)							(COUNTY)
DATE CHILD WAS FOUND:	(MONTH)	(DAY)	(YEAR)	SEX	RACE	APPROXIMATED AGE:
DATE CHILD WAS FOUND:
NAME OF CUSTODIAN:	(PERSON OR INSTITUTION)
MAILING ADDRESS OF CUSTODIAN:
CHILD FOUND BY:
MAILING ADDRESS OF FINDER:
REPORTED TO REGISTRAR ON:	(SIGNED)						LOCAL REGISTRAR

ILLINOIS DEPARTMENT OF PUBLIC HEALTH – DIVISION OF VITAL RECORDS

VR 102 (2/79)

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

                    
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