Ill. Admin. Code tit. 77, pt. 500, app H, ILLUSTRATION D

Current through Register Vol. 49, No. 2, January 10, 2025

Abstract of a Record

This record states the following concerning the person named above.

(Here copy the EXACT WORDING of the record which relates to (1) the name of the child, (2) the date of birth, (3) the place of birth, (4) the father's name, (5) the mother's maiden name.)

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COMMENTS ON CHANGES OR ERASURES:

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I hereby certify that I have examined the record above described; that it contains the entries above set forth; that there is apparently no erasure or amendment of the birth or other essential information except as explained above; and that the appearance of the paper and ink of said record indicates that the entries were made at least _____ years ago.

Date

______________________

Signed

_______________________

(SEAL)

Title

_________________________

Address

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VR - 154e

State of Illinois - Department of Public Health - Bureau of Vital Records

Ill. Admin. Code tit. 77, pt. 500, app H, ILLUSTRATION D

Added at 15 Ill. Reg. 11706, effective August 1, 1991