§500.ILLUSTRATION C. Information Concerning Parents

Division of Vital Records 605 W. Jefferson St. Springfield, IL  62702
FULL NAME OF CHILD

 

 

INFORMATION CONCERNING PARENTS

 

FATHER

MOTHER

Full Name

Full Maiden Name

Residence at the time this child was born

Residence at the time this child was born

(if rural, give township or road district)

(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

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.

DO NOT COUNT THIS CHILD.

 

(a)     Number			(b)     Number BORN alive				(c)     Number
still living		but now dead				born dead

 

 

SIGNATURE:
DATE:

 

VR168.1 (2/88)

 

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