§500.ILLUSTRATION D. Application for Search of Death Record Files

APPLICATION FOR SEARCH OF DEATH RECORD FILES

The fee for a search of the files is $10.00.  If the record is found, one *CERTIFICATION is issued at no additional charge.  Additional certifications 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.   The fee for a 5 years search for genealogical research is $10.00.  If found, one UNCERTIFIED copy of the record will be issued at no additional charge.  Each additional year searched is $1.00.  NOTE:  STATE DEATH RECORDS BEGAN JANUARY 1, 1916.

*

A CERTIFICATION shows only the name of deceased, sex, place of death, date of death, date filed, and certificate number.

*

A FULL CERTIFIED COPY is an exact photographic copy of the original death certificate.

CERTIFIED COPY

CERTIFICATION

GENEALOGICAL RESEARCH

$15.00 Each

$10.00 Each

Amount Enclosed:  $

Amount Enclosed:  $

Amount Enclosed:  $

for

copies

for

copies

for

year search

(DO NOT SEND CASH)

Make check or money order payable to:

Illinois Department of Public Health.

First

Middle

Last

FULL NAME OF

DECEASED:

PLACE OF

Hospital

City or Town

County

DEATH:

DATE OF

Month

Day

Year

SEX:

RACE:

OCCUPATION:

DEATH:

DATE LAST KNOWN

Month

Day

Year

LAST KNOWN

MARITAL STATUS:

TO BE ALIVE:

ADDRESS:

DATE OF

Month

Day

Year

BIRTHPLACE:

NAME OF HUSBAND

BIRTH:

(City and State)

OR WIFE:

FULL NAME OF FATHER

FULL MAIDEN NAME OF MOTHER

OF DECEASED:

OF DECEASED:

APPLICATION MADE BY:

MAIL COPY TO:

(if other than applicant)

NAME:

NAME:

FIRM NAME:

FIRM NAME:

(if any)

(if any)

STREET

STREET

ADDRESS:

ADDRESS:

CITY:

STATE:

ZIP:

CITY:

STATE:

ZIP:

VR  280  (5/87R)  DIV.  OF  VITAL  RECORDS,  ILLINOIS  DEPT.  OF  PUBLIC  HEALTH,  SPRINGFIELD,  IL.  62702

 

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