Illinois Administrative Code (Last Updated: March 27, 2024) |
TITLE77. PUBLIC HEALTH |
PART500. ILLINOIS VITAL RECORDS CODE |
Section500.APPENDIX E. Adoption Records |
§500.ILLUSTRATION B. Information Concerning Adoptive Parents
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DEPARTMENT OF PUBLIC HEALTH
DIVISION OF VITAL RECORDS
605 W. JEFFERSON ST.
SPRINGFIELD, IL 62702-5097
RE: ADOPTION OF (Child's name by adoption):
_______________________________________________________________
_______________________________________________________________
INFORMATION CONCERNING ADOPTIVE PARENTS
(Information should be given as existed when child was born)
ADOPTIVE FATHER
ADOPTIVE MOTHER
Full
Name
Full
Maiden Name
Residence at the time this child was born
(if rural, give township or road district)
Residence at the time this child was born
(if rural, give township or road district)
Street
Street
City or Place & State or Country
City or Place & State or Country
Color or Race
Color or Race
Date of Birth
Date of Birth
Place of Birth
Place of Birth
Social Security #
Social Security #
Occupation (at time this child was born)
Occupation (at time this child was born)
List below all OTHER children of this mother who were born BEFORE this child was born, counting children BORN to her and other children ADOPTED by her. DO NOT COUNT THIS CHILD.
(a) Number still living ___ (b) Number BORN alive but now dead ___ (c) Number born dead ___
(signature of one adoptive parent)
Date:
VR 168 (3/91)
(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)