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REGISTER OF BIRTHS.

Date of 1. Nationality Race birth.

of

1. Full name of

1. Name and address of 1. Nationality mother.

medical attendant. of mother

1. Full name of Age.

2. Name and address of
2. Maiden name
2.

Age.
Place of

father.
of mother.

person making certi-
birth.
3.

Occupation.
Residence of

ficate.
mother

3. Returned by.

3.

3.

1. Name of

child.
Date of 2.
No.
return. 3. No.of child

of this moth-
er.

of father. or

2. Place of 2. Place color. birth.

birth.

2..

3.

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3

REGISTER OF DEATHS.

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How

1. Complicalong

1. Name of Name and Single, 1. Na

1 Place

tion. resi

1. Place

Under- residence of
of death. 2. Duration of of burial
married, tionality dent in

taker
widower 2. Where

Physician re-
2. Cause complication. 2. Date of

this or widow

2. Place of turning certi-
born.

of death. 3. Duration of buriai
state.

business. ficate.
disease.
YEARS.

Month,

Day. Year

A. M.

or
P. M.

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REGISTER OF PHYSICIANS AND ACCOUCHEURS.

County, Illinois.

Certificate of state board
NAME.

of health.
School
Residence and

No. of

When said
When The signa-
P. O. address.

No. of
of

years in

Why issued.
register-ture of the

If diploma or
Give street Age. Nativity. years in
ed.

practice Date of based upon diplo- license was
party is re-

prac

and No. if in

tice.
quired.

certifi- ma or license, givel conferred.
city or village.

practice. in Illinois.

cate. name of institu

tion.

When certifi

cate from
state board of

health was
filed for re-

cord.

Remarks

..

The following Forms among others were adopted by the Board of Health and are now in use throughout the State.

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Pe This Return is to be carefully filled out and attached to and returned with the marriage license. This return does not take the place of the Certificate which comes attached to the License, but is in addition theretii.

Return of a Marriage to County Clerk.

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1. Name of Groom
2. Place of residence
3. Occupation..
4. Age next birthday years, color, race,
5. Place of birth
6. Fathe 's name...
7. Mother's maiden name..
8. Number of groom's marriage.
9. Full name of Bride

Maiden name, if a widow.
10. Place of residence.
11. Age next birthday years, color,

race,
12. Place of birth
13. Father's name...
14. Mother's maiden name
15. Number of bride's marriage
16. Married at

in the County of

.and State of Illinois, the.
day of

.18...
17. Witnesses to marriage.

1. Full name of groom.
2. Place of residence
3. Occupation..
4. Age next birthday

years, color,

race,
5. Place of birth.
6. Father's name.....
7. Mother's maiden name
8. Number of groom's marriage.
9. Full name of Bride....

Maiden name, if a widow
10. Place of residence.
11. Age next birthday

years, color.

race,
12. Place of birth
13. Father's name...
14. Mother's maiden name
15. Number of bride's marriage
16. Married at..
in the County of.

and State of Illinois, the....day of.
17. Witnesses to Marriage,

N. B.-At Nos. 8 and 15 state whether 1st, 2d, 3d, 4th, &c., Marriage of each. At 17 give
names of subscribing witnesses to the Marriage Certificate. If no subscribing witnesses, give
names of two persons wito witnessed the coremony.

18..

N. B.-At Nos. 8 and 15 state whether 1st, 2d,
3d, &c., marriage of each. At 17 give names of
subscribing witnesses to the marriage certificate.
If no subscribing witnesses, give names of two
persons who witnessed the ceremony.

18..

18.
We hereby certify that the information above
given is correct, to the best of our knowledge
and belief.

.(Groom.)

.(Bride.)
I hereby certify that the above is a correct re-
turn of a marriage solemnized by me.

We hereby certify that the information above given is correct,
to the best of our knowledge and belief.
.(Gcoom.)

.(Bride.)
I hereby certify that the above is a correct return of a marriage solemnized by me.
Dated at

}

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M. D.

*The given name of child should be certified, if possible, when this certificate is made, and should, in any case, be certified and registered within a year. +City, number, street and ward; same in towns that have them; township or precinct.

Residence

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