Form Vr 181 - Application Form For Search Of Birth Record Files Of A Deceased Individual
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1Application for Search of Birth Record Files
State of Illinois
Illinois Department of Public Health
of a Deceased Individual
The state began recording birth records on January 1, 1916.
Birth Information
DECEDENT'S BIRTH NAME (First, Middle, Last Prior to First Marriage/Civil Union)
PLACE OF BIRTH (Hospital, City or Town, County)
DATE OF BIRTH (Month, Day, Year)
SEX
BIRTH CERTIFICATE NUMBER (if known)
FATHER/CO-PARENT'S NAME (First, Middle, Last Prior to First Marriage/Civil Union)
MOTHER/CO-PARENT'S NAME (First, Middle, Last Prior to First Marriage/Civil Union)
MUST PROVIDE COPY OF DEATH CERTIFICATE AS PROOF OF DEATH
Information about the Death of the Individual
Individual Requesting Copies
LEGAL NAME AT TIME OF DEATH (First, Middle, Last)
PRINT NAME (First, Middle, Last)
NAME PRIOR TO FIRST MARRIAGE/CIVIL UNION
STREET ADDRESS
DATE OF DEATH (Month, Day, Year)
CITY, STATE, ZIP
PLACE OF DEATH (City, State)
SOCIAL SECURITY NUMBER
DRIVER'S LICENSE NUMBER/STATE OF ISSUE
I affirm, under the penalties for perjury, that the representations
made on this application are true to the best of my knowledge
RELATIONSHIP TO DECEDENT
and belief.
________________________________________________
Signature
Date
Home Telephone _________________________________
Work telephone _________________________________
IL Law (ILCS410/535/25(1)) requires advance payment for search of files. This $10.00 search fee is non-refundable.
Additional copies of the same record requested 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 and a legible copy of your non-expired, government issued photo ID.
(see
other side for acceptable proof of ID)
DO NOT SEND CASH — Make check or money order payable to ILLINOIS DEPARTMENT OF PUBLIC HEALTH.
Birth certificate (with following items: name, date of birth, sex,
Birth certificate (with information collected at the time of birth
place of birth, mother/co-parent’s maiden name,
- information has varied throughout the years)
mother/co-parent’s place of birth, mother/co-parent’s age,
$15.00 first copy
$2.00 each additional copy
father/co-parent’s name, father/co-parent’s place of birth,
father/co-parent’s age, file date, date issued and State File number)
Amount enclosed $__________for ________ total copies
$10.00 first copy
$2.00 each additional copy
Amount enclosed $__________for ________ total copies
MAIL TO:
Illinois Department of Public Health, Division of Vital Records, 925 E. Ridgely Avenue, Springfield, IL 62702-2737
For more information -
VR 181 (Rev. 8/14)
Printed by Authority of the State of Illinois
IOCI 15-218
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