Rock Island County Health Department
Health Promotion & Education Group * Vital Records
APPLICATION FOR CERTIFIED COPY OF VITAL RECORD
Under Illinois State Law (410 ILCS 535 – Vital Records Act) only specific individuals have legal access to
birth and death certificates. The Rock Island County Health Department Vital Records program will issue
certificates only to authorized individuals. To do otherwise is a violation of Illinois law. Vital Records are
not considered public information, nor are they subject to the Freedom of Information Act.
To obtain a Birth Record, you must be:
Of legal age (18 or an emancipated minor) if requesting your own birth certificate.
The mother of the child whose birth certificate is being requested.
The father of the child if you are listed on the birth certificate. A father who is not listed on the
birth certificate does not have legal access to a copy of that certificate.
A legal Guardian with documentation to show this.
$12.00 1
st
Certified Copy/$6.00 Add’l copies of same record at the same time
To obtain a Death Record, you must be
The informant listed on the death certificate.
The next of kin.
Someone who has a personal or property right interest in the record, and documentation to show
this.
$17.00 1
st
Certified Copy/$11.00 Add’l copies of same record at the same time
YOU MUST SHOW A PHOTO I.D. IN ORDER TO RECEIVE A VITAL RECORD
(copy of photo I.D. must be submitted with mail orders)
Type of Record Requested: ___ Birth ___ Death
Full Name
of Person on Record
First Middle Last
Place of
___ Birth / ___ Death
Hospital City or Town State
Date of
___ Birth / ___ Death
Month Day Year
Mother’s Name
on Record
First Middle Maiden Name Current Married Name
Father’s Name
on Record
First Middle Last
Record Requested By: Date
(Your Written Signature)
Address
Your Relationship to the Name on the Record: ___ Self ___ Mother ___ Father ___ Other
(If OTHER, please explain)
Intended Use of Record
Number of Copies
Rock Island County Health Department * Vital Records * 2112 25
th
Ave. * Rock Island, IL 61201 * 309-558-2940
