APPLICATION FOR SEARCH OF BIRTH RECORD FILES

The fee for a search of the files is $10.00.  If the record is found one CERTIFICATION or BIRTH CARD is issued at no additional charge.  Additional certifications or birth cards 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.  Please indicate below the type and number of copies requested and return this form with the proper fee.  DO NOT SEND CASH.  Make check or money order payable to:  Illinois Department of  Public Health.

CERTIFIED COPY

CERTIFICATION

BIRTH CARD   (wallet size)

$15.00 Each

$10.00 Each

$10.00  Each

Amount Enclosed:

$

Amount Enclosed:

$

Amount Enclosed:

$

for

copies

  for

copies

    for

copies

First

Middle

Last

FULL

NAME:

PLACE OF

BIRTH:

Street, RFD., Hosp.

City or Town

County

DATE OF BIRTH:

Month

Day

Year

SEX:

BIRTH NUMBER IF KNOWN:

FATHER:

MOTHER:

Maiden Name

Married Name

Application Made By:

Mail Copy to (if other than applicant):

NAME:

NAME:

(written signature)

STREET

STREET

ADDRESS:

ADDRESS:

CITY:

STATE:

ZIP

CITY

STATE:

ZIP

YOUR RELATIONSHIP

TO PERSON:

INTENDED USE OF

DOCUMENT: