§500.ILLUSTRATION E. Application for Search of Birth Record Files

 

APPLICATION FOR SEARCH OF BIRTH RECORD FILES

The fee for a search of the files is $10.00.  If the record is found one CERTIFICATION or BIRTH CARD is issued at no additional charge.  Additional certifications or birth cards of the same record ordered at the same time are $2.00 each.  The fee for a FULL CERTIFIED COPY is $15.00.  Additional certified copies of the same record ordered at the same time are $2.00 each.  Please indicate below the type and number of copies requested and return this form with the proper fee.  DO NOT SEND CASH.  Make check or money order payable to:  Illinois Department of  Public Health.

CERTIFIED COPY

CERTIFICATION

BIRTH CARD   (wallet size)

$15.00 Each

$10.00 Each

$10.00  Each

Amount Enclosed:

$

Amount Enclosed:

$

Amount Enclosed:

$

for

copies

for

copies

for

copies

First

Middle

Last

FULL NAME:

PLACE OF BIRTH:

Street, RFD., Hosp.

City or Town

County

DATE OF BIRTH:

Month

Day

Year

SEX:

BIRTH NUMBER IF KNOWN:

FATHER:

MOTHER:

Maiden Name

Married Name

 

Application Made By:						Mail Copy to (if other than applicant):
NAME:						NAME:
	(written signature)
STREET						STREET
ADDRESS:						ADDRESS:
CITY:		STATE:	ZIP			CITY		STATE:	ZIP
YOUR RELATIONSHIP TO PERSON:						INTENDED USE OF DOCUMENT:

 

NOTE:  Birth certificates are confidential records, and copies can be issued only to persons entitled to receive them.  The application must indicate the requestor's relationship to the person and the intended use of the document.  (SEE OTHER SIDE)

 

 

 

VR.  180 (5/87R)-DIVISION OF VITAL RECORDS-605 WEST JEFFERSON STREET-ILLINOIS DEPARTMENT OF PUBLIC HEALTH, SPRINGFIELD, ILLINOIS  62702

 

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