STATE OF ILLINOIS

RECORD OF A FOREIGN BIRTH

(ORIGINAL)

STATE FILE NO.

Z –

1.  PLACE OF BIRTH:

(CITY)

(COUNTRY)

2.  NAME OF CHILD:

3.  DATE OF BIRTH:

(MONTH)

(DAY)

(YEAR)

4.  SEX

5.  FATHER'S FULL NAME:

6.  FATHER'S

BIRTH DATE:

(MONTH)

(DAY)

(YEAR)

7.  FATHER'S

BIRTHPLACE:

(CITY OR COUNTY)

(STATE OR COUNTRY)

8.  MOTHER'S MAIDEN NAME:

9.  MOTHER'S

BIRTH DATE:

(MONTH)

(DAY)

(YEAR)

10.  MOTHER'S

       BIRTHPLACE:

(CITY OR COUNTY)

(STATE OR COUNTRY)

OFFICE OF VITAL RECORDS – ILLINOIS DEPARTMENT OF PUBLIC HEALTH – SPRINGFIELD 62761

I HEREBY CERTIFY that this record is the original certificate of birth as established under the provisions of the Illinois Vital Records Act.

Date Filed

State Registrar

Springfield, Illinois

By ________________________________________

Deputy State Registrar

KIND OF DOCUMENT AND DATE MADE

BIRTH FACTS ESTABLISHED