TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER e: VITAL RECORDS
PART 500
ILLINOIS VITAL RECORDS CODE
SECTION 500.APPENDIX H AFFIDAVITS
Section 500.APPENDIX H Affidavits
Section 500.ILLUSTRATION D Abstract
of a Record
(FILL OUT THIS ABSTRACT
EITHER BY TYPEWRITER OR BY HANDLETTERING IN PERAMENT BLACK OR BLUE BALCK INK)
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ABSTRACT
OF A RECORD
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ABSTRACT MUST BE MADE BY A
CLERK OF COUNTY COURT OR NOTARY PUBLIC OVER HIS SIGNATURE AND SEAL
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This
is a
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record
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(Bible, Family History, School Census, Employment,
Etc.)
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pertaining
to
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(Name of Individual)
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The
record is filed under No.
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, Volume
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, Page
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Dated
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and
is in the custody of
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(Name)
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(Address)
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This
record states the following concerning the person named above.
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(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.
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Date
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Signed
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(SEAL)
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Title
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Address
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VR
– 154e
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State of Illinois – Department of Public Health –
Bureau of Vital Records
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(Source: Added at 15 Ill. Reg. 11706, effective August 1, 1991)
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