§500.ILLUSTRATION F. Application for Correction of a Birth Certificate

APPLICATION FOR CORRECTION OF A BIRTH CERTIFICATE

 

MAIL TO:          Illinois Department of Public Health

Office of Vital Records

605 West Jefferson

Springfield, Illinois  62761

 

I wish to have errors corrected on the birth certificate identified as follows:

 

FULL NAME

OF CHILD:

PLACE

OF BIRTH:

HOSPITAL

COUNTY

CITY, VILLAGE, TOWNSHIP

DATE

REGISTERED

STATE FILE

OF BIRTH:

NUMBER

NUMBER

MONTH           DAY           YEAR

MOTHER'S

MAIDEN NAME:

FATHER'S NAME AS

LISTED ON BIRTH RECORD:

Please give us the INCORRECT and CORRECT information below:

INCORRECT INFORMATION

CORRECT INFORMATION

SHOULD READ

PRINT

PRINT

SHOULD READ

PRINT

PRINT

SHOULD READ

PRINT

PRINT

SHOULD READ

PRINT

PRINT

SHOULD READ

PRINT

PRINT

ADDITIONAL COMMENTS:

Please mail correction forms to:

WRITTEN SIGNATURE:

ADDRESS:

DATE:

MY RELATIONSHIP TO CHILD:

VR – 401.1  REV. 6/75

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