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REGISTER OF BIRTHS.
Date of 1. Nationality Race birth.
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
person making certi-
3. Returned by.
1. Name of
of this moth-
of father. or
2. Place of 2. Place color. birth.
REGISTER OF DEATHS.
1. Name of Name and Single, 1. Na
Under- residence of
this or widow
2. Place of turning certi-
of death. 3. Duration of buriai
REGISTER OF PHYSICIANS AND ACCOUCHEURS.
Certificate of state board
If diploma or
practice Date of based upon diplo- license was
and No. if in
certifi- ma or license, givel conferred.
practice. in Illinois.
cate. name of institu
The following Forms among others were adopted by the Board of Health and are now in use throughout the State.
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.
1. Name of Groom
Maiden name, if a widow.
in the County of
.and State of Illinois, the.
1. Full name of groom.
Maiden name, if a widow
and State of Illinois, the....day of.
N. B.-At Nos. 8 and 15 state whether 1st, 2d, 3d, 4th, &c., Marriage of each. At 17 give
N. B.-At Nos. 8 and 15 state whether 1st, 2d,
We hereby certify that the information above given is correct,