PERSONAL DATA BASED ON ADOPTION NEEDED TO PREPARE THE NEW BIRTH CERTIFICATE

CHILD

1.

CHILD'S NEW NAME

(First)

(Middle)

(Last)

FATHER

2.

Father's

(First)

(Middle)

(Last)

3.  Father's Birth Date

Full

Name

4.

Father's

(State or foreign country)

5.  Color or Race

6a.  Usual Occupation

6b.  Kind of Business or Industry

Birth

Place

MOTHER

7.

Mother's

(First)

(Middle)

(Last)

8.  Mother's Birth Date

Maiden

Name

9.

Mother's

(State or foreign country)

10.  Color or Race

11.  Mother's Usual Residence (City, Town or Twsp. County & State)

Birth

Place

12.

How many OLDER children of this Mother

a.  Are now living?

b.  Are now dead?

c.  Were born dead?

(including adopted ones).

13.

A new certificate of birth

  is

  is not

to be prepared and filed.

VERIFICA-TION OF ABOVE DATA

14.

Signature of Parents Verifying above Personal Data

15.  Present Complete Mailing Address of Adoptive Parents

ATTORNEY

16.

Name of Attorney and Law Firm

17.  Attorney's Mailing Address

PERSONAL DATA NEEDED TO IDENTIFY ORIGINAL BIRTH CERTIFICATE (Which will be removed to a Sealed File)

18.

Child's

(First)

(Middle)

(Last)

19.  State Birth Certificate Number if Known

Name

at Birth

20. 

Sex

21.

Date

(Mo)

(Day)

(Yr.)

22.  Place of Birth

a. State

b. County

c. City, Village or Twsp.

d. Hospital

of

Birth

23.

Maiden Name

(First)

(Middle)

(Last)

of Natural

Mother

24.

Full Name

(First)

(Middle)

(Lasts)

of Natural

Father

CERTFICATION OF  CLERK  OF COURT

25.

STATE OF ILLINOIS

Case Number

CIRCUIT COURT OF

COUNTY

Date of Decree

I hereby certify that the child identified at item 18 was adopted by the parent(s) named at items 2 and 7, and is now to bear the name shown at item number 1, as set forth in the Decree of Adoption.

COURT

SEAL

Signed

, Clerk

Date Signed

at

, Illinois