PACKAGE INSTRUCTIONS

*. Verify and print your application documents

• Make sure all information on the forms are

correct

• If you notice an error, contact us

immediately to request an updated form.

2. Include these documents related to:

MICHELLE SILVER

• Photocopy of Driver's license

3. Pay the mandatory application fee to the

Health Department

Please use one of the following payment

methods: personal check, money order or

cashier check

• Pay to: ILLINOIS DEPARTMENT OF PUBLIC HEALTH

• AMOUNT: $15.00

4. Apply the provided label on an envelope

Cut and tape the provided OUTER LABEL onto a

large envelope

5. Gather your documents into the labeled

envelope

• State fees payment selected in Part 3

• Application form signed

• Photocopy of Driver's license

6. Mail your application

Mail from the nearest USPS store or post box

drop off

PLEASE DO NOT ADD THIS PAGE IN THE FINAL ENVELOPE

NOTE: Birth Certificates are confidential records and copies can only be issued to a person entitled to receive them. The application must indicate the requestor’s relationship to the person listed on the record and indicate the intended use of the document. For additional information please see reverse side or visit our website at www.dph.illinois.gov/topics-services/birth-death-other-records. VR 180 (Rev. 10/18) Printed by Authority of the State of Illinois P.O.#1419166 10M 10/18 IOCI 19-303 State of Illinois

Illinois Department of Public Health

Application for Illinois Birth Record

Birth Certificate - Long Form

Accepted for all legal use, passport and other governmental agencies

(contains the most available information)

$15.00 first copy $2.00 each additional copy

Amount enclosed $ for total copies Birth Certificate - Short Form

Basic birth record information, may not be accepted by all governmental agencies

$10.00 first copy $2.00 each additional copy

Amount enclosed $ for total copies Foreign Birth / Administrative Foreign Birth Record Birth record of adopted person born outside of the United States who were re-adopted in Illinois

$5.00 each copy

Amount enclosed $ for total copies Genealogical

Uncertified records for a birth 75 years and older

(not for legal use)

$10.00 first copy $2.00 each additional copy

Amount enclosed $ for total copies DO NOT SEND CASH — Make check or money order payable to ILLINOIS DEPARTMENT OF PUBLIC HEALTH (IDPH). For records prior to 1916, contact the County Clerk in the County where the birth took place BLANK SPACE FOR OFFICE USE BIRTH CERTIFICATE NUMBER IF KNOWN (Not Required) FULL NAME ON BIRTH RECORD (First, Middle, Last) As listed on Birth Record DATE OF ILLINOIS BIRTH (Month, Day, Year) PLACE OF ILLINOIS BIRTH (City and or County) SEX MOTHER / CO-PARENT’S NAME (Maiden Name Before First Marriage Required) As listed on Birth Record FATHER / CO-PARENT’S NAME As listed on Birth Record NAME OF INDIVIDUAL REQUESTING COPIES: REQUESTER RELATIONSHIP (Mother, Father, Legal Guardian etc.) REQUESTER ADDRESS CITY STATE ZIP CODE

INTENDED USE REQUESTER PHONE NUMBER REQUESTER EMAIL ADDRESS MAIL TO ADDRESS IF DIFFERENT THAN ABOVE CITY STATE ZIP CODE SIGNATURE REQUIRED DATE

Complete Form IN FULL, Sign, Include Copy of Identification & Proper Fee MAIL TO: IDPH Vital Records, 925 E. Ridgely Avenue, Springfield, IL 62702-2737 For additional information - www.dph.illinois.gov/topics-services/birth-death-other-records IF THE BIRTH DID NOT OCCUR IN ILLINOIS YOU MUST CONTACT THE STATE WHERE THE BIRTH TOOK PLACE

978-***-****

Michelle Silver

10 VALLIRIA DR

Fred Silver

Diane Carol Zelan

15

GROTON

06/10/1971 Chicago, Cook County, Illinois female

MA

Michelle Silver

05/30/2021

Drivers license adpz94@r.postjobfree.com

01450-1545

1

Self

PRE PAID MAILING LABEL

Please use this mailing label to mail your complete application to the Health Department.

Cut this label and affix to the back of any size flat envelope and drop it to any USPS post office

OUTER ENVELOPE

Contact this candidate