Illinois Administrative Code (Last Updated: March 27, 2024) |
TITLE77. PUBLIC HEALTH |
PART500. ILLINOIS VITAL RECORDS CODE |
Section500.APPENDIX F. Death Records |
§500.ILLUSTRATION F. Application for Correction of a Death Certificate
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APPLICATION FOR CORRECTION OF A DEATH CERTIFICATE
MAIL TO:
ILLINOIS DEPARTMENT OF PUBLIC HEALTH
OFFICE OF VITAL RECORDS
535 WEST JEFFERSON
SPRINGFIELD, ILLINOIS 62761
PLEASE SEND ME FORMS AND INSTRUCTION FOR CORRECTING THIS DEATH CERTIFICATE:
Full name of deceased:
Registered Number:
Date of death:
month
day
year
State file number:
Place of death:
hospital
county
city, village or township
FILL IN ONLY ITEMS TO BE CORRECTED
incorrect information now on certificate
should be corrected to read:
Name of Deceased:
Date of death:
Usual residence:
state
county
city, village or township
Married, never married, widowed, or divorced:
Birth date and age:
birth date
age
Birthplace:
Father’s name:
Mother’s maiden name:
other corrections needed:
Please mail correction forms to:
Name:
Address:
Date:
My relationship to deceased:
VR-401.2 REV. 6/78
(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)