§500.ILLUSTRATION B. Delayed Record of Birth

VR-141A (1978)

Type or Print in PERMANENT INK

REGISTRATION DISTRICT NO

DELAYED RECORD OF BIRTH

CHILD'S BIRTH NUMBER

(AGE 12 MONTHS TO 7 YEARS)

112-

THIS IS A PERMANENT RECORD • USE TYPEWRITER WITH BLACK RIBBON OR PRINT WITH PEN USING BLACK INK • ALL SIGNATURES MUST BE HAND WRITTEN IN PEN AND INK THIS DELAYED RECORD OF BIRTH MUST BE EXECUTED IN ACCORDANCE WITH THE PROVISIONS OF PARAGRAPH 73–14 OF THE VITAL RECORDS ACT

CHILD – NAME

FIRST

MIDDLE

LAST

DATE OF BIRTH (MONTH DAY YEAR)

1.

2a.

HOUR

SEX

HOSPITAL - NAME

(IF NOT IN HOSPITAL, GIVE STREET AND NUMBER)

CHILD

2b.

M.

3.

4a.

CITY, TOWN, TWP. OR ROAD DISTRICT NO.

COUNTY

4b.

4c.

MOTHER – MAIDEN NAME

FIRST

MIDDLE

LAST

AGE (AT TIME OF THIS BIRTH)

STATE OF BIRTH (IF NOT IN U.S.A.  NAME COUNTRY)

5a.

5b.

5c.

MOTHER

RESIDENCE

STREET AND NUMBER

CITY, TOWN, TWP. OR ROAD DISTRICT NO

INSIDE CITY (YES/NO)

COUNTY

STATE

6a.

6b.

6c.

6d.

6e.

MOTHER'S COMPLETE MAILING ADDRESS

STREET AND NUMBER OR R.F.D.

CITY OR TOWN

STATE

ZIP

7.

FATHER

FATHER –  NAME

FIRST

MIDDLE

LAST

AGE (AT TIME OF THIS BIRTH)

STATE OF BIRTH (IF NOT IN U.S.A.  NAME COUNTRY)

8a.

8b.

8c.

THIS RECORD SHALL BE PRESENTED FOR FILING TO THE STATE REGISTRAR OF VITAL RECORDS AT SPRINGFIELD.   WHEN ACCEPTED AND FILED AN EXACT COPY WILL BE FURNISHED THE COUNTY CLERK OF THE COUNTY IN WHICH THE BIRITH OCCURRED.

9. AFFIDAVIT:  I HEREBY DECLARE UPON OATH THAT THE ABOVE STATEMENTS ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF.

a.) SIGNED:

b.) ADDRESS

(PARENT – LEGAL GUARDIAN)

(SEAL)

c.) SUBSCRIBED AND SWORN TO BEFORE ME THIS

DAY OF

,

19

AT

(PLACE)

COUNTY CLERK OR NOTARY PUBLIC

APPLICANT!  DO NOT WRITE BELOW THIS LINE

KIND OF DOCUMENT AND DATE MADE

INFORMATION GIVEN IN DOCUMENT AS TO BIRTH DATE, BIRTHPLACE, AND PARENTS

ABSTRACT OF SUPPORTING EVIDENCE

DOCUMENT NO. 1

AGE OR BIRTH DATE:

BIRTHPLACE:

FATHER:

MOTHER:

DOCUMENT NO. 2

AGE OR BIRTH DATE:

BIRTHPLACE:

FATHER:

MOTHER:

DOCUMENT NO. 3

AGE OR BIRTH DATE:

BIRTHPLACE:

FATHER:

MOTHER:

DOCUMENT NO. 4

AGE OR BIRTH DATE:

BIRTHPLACE:

FATHER:

MOTHER:

ACCEPTED AND FILED AT SPRINGFIELD FOR THE STATE REGISTRAR OF VITAL RECORDS

BY

,

DEPUTY STATE REGISTRAR, ON

,

19

THIS RECORD IS VALID ONLY IF IT HAS BEEN ACCEPTED BY AND FILED WITH THE STATE REGISTRAR OF VITAL RECORDS AT SPRINGFIELD, ILLINOIS

OFFICE OF VITAL RECORDS – ILLINOIS DEPARTMENT OF PUBLIC HEALTH – SPRINGFIELD 62761