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