SUBREGISTRAR'S APPOINTMENT BLANK

I,

, Local Registrar of Registration District

No.

County, Illinois, hereby request the State Registrar

of Vital Records to approve my appointment of the individual listed below as Subregistrar of Subregis-

tration District No.

, effective

,19

.

Miss

Mrs.

Mr.

(Name of Subregistrar)

(Local Title, if any, i.e., City Clerk)

Subregistration Office Address

, Illinois

(Zip Code)

Telephone Numbers: Office

Residence

Area Code

The area in which I authorize this Subregistrar to serve is:

Anywhere within my Local Registration District.

Restricted to these areas:

Signed:

, Local Registrar

Address:

Dated:

, 19

, Illinois

(Zip Code)

APPROVED this

day of

, 19

, M.D.

Director, Illinois Department of Public Health; and

State Registrar of Vital Records, Springfield, Illinois

NOTE:

Local Registrar should fill in and submit this form in triplicate to the Office of Vital Records, Illinois Department of Public Health, Springfield, Illinois, 62761. If the appointment is approved, the Department will retain one copy and return two to the Local Registrar, one for his files and one for the Subregistrar. An engraved certificate will also be sent the Local Registrar to present to the Subregistrar.

VR 303 (2/75)