Illinois Administrative Code (Last Updated: March 27, 2024) |
TITLE77. PUBLIC HEALTH |
PART500. ILLINOIS VITAL RECORDS CODE |
Section500.APPENDIX H. Affidavits |
§500.ILLUSTRATION C. Affidavit and Certificate of Correction
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NOT FOR USE ON RECORDS FILED PRIOR TO JANUARY 1, 1916
68555 25M 9-88
For Original Record
STATE OF ILLINOIS
AFFIDAVIT AND CERTIFICATE OF CORRECTION
Concerning the record of:
birth
FULL NAME
whose stillbirth occurred
death
at
in the County of
, Illinois on the
day of
19
In keeping with the provisions of Paragraph 73-22 of the Vital Statistics Act, Paragraph 73-1 through 73-29, Chapter 111½, Illinois Revised Statutes, 1961, as amended, I hereby certify under oath that the following items appearing on the original certificate identified above are incorrect or missing and should be corrected as follows:
omitted
ITEM No.
was incorrectly given as
and SHOULD READ
omitted
ITEM No.
was incorrectly given as
and SHOULD READ
omitted
ITEM No.
was incorrectly given as
and SHOULD READ
omitted
ITEM No.
was incorrectly given as
and SHOULD READ
omitted
ITEM No.
was incorrectly given as
and SHOULD READ
omitted
ITEM No.
was incorrectly given as
and SHOULD READ
Address
Street & No.
Signed
City & State
Relationship
Subscribed and sworn to before me this
day of
19
Address
Street & No.
Signed
City & State
Title
Documents Accepted as Supporting Evidence
1
Date made
2
Date made
3
Date made
4
Date made
5
Date made
Accepted for filing on the
day of
19
By
Title
..................................................
VR-400
OFFICE OF VITAL RECORDS – ILLINOIS DEPARTMENT OF PUBLIC HEALTH – SPRINGFIELD 62761
Printed by the Authority of the State of Illinois
(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)