State of Illinois
Illinois Department of Public Health
Application for Search of Birth Record Files
of a Deceased Infant
VR181 (Rev. 12/16)
IOCI 17-276
Section B - Child's Information Section C - Applicant Information
FULL LEGAL NAME OF INFANT
(First, Middle, Last)
NAME (First, Middle, Last)
STREET ADDRESS
DATE OF BIRTH (Month, Day, Year) CITY, STATE, ZIP CODE
PLACE OF DEATH (City, State) SOCIAL SECURITY NUMBER
ARE YOU THE MOTHER OF THE DECEASED INFANT?
❑ Yes ❑ No
DRIVER'S LICENSE/STATE ID NUMBER STATE ISSUED
I affirm, under the penalties for perjury, that the representations made on this application are true to the best of my knowledge
and belief.
__________________________________________________________________ ___________________
Signature Date
Certified Copy
$15.00
I have received at least one certified copy
of this record prior to this request.
Work Telephone _____________________
Home Telephone _____________________
❑ Yes ❑ No
Application Instructions
The application must be completed by the mother listed on the birth certificate of the deceased child. To qualify
for a copy of a birth record for a deceased infant without the deceased stamp, the child must have died within 90
days of the birth. Additionally, the request must be made within nine months from the date of death.
Only the mother of the child named on the birth certificate is entitled to order one certified copy of the birth certificate
that is not marked “DECEASED.” The cost for the certified copy is $15. The application must be fully completed
(all boxes) or it will be returned to the requestor.
DO NOT SEND CASH — Make check or money order payable to Illinois Department of Public Health.
Mail to: Division of Vital Records
925 E. Ridgely Ave.
Springfield, IL 62702-2737
Section A - Birth Information
NAME (First, Middle, Last)
PLACE OF BIRTH (Hospital, City or Town, County)
DATE OF BIRTH (Month, Day, Year) SEX BIRTH CERTIFICATE NUMBER (if known)
FATHER/CO-PARENT’S CURRENT LEGAL NAME (First, Middle, Last)
FATHER/CO-PARENT’S NAME PRIOR TO FIRST MARRIAGE/CIVIL UNION (First, Middle, Last)
MOTHER/CO-PARENT'S CURRENT LEGAL NAME (First, Middle, Last)
MOTHER/CO-PARENT'S NAME PRIOR TO FIRST MARRIAGE/CIVIL UNION (First, Middle, Last)
