Application for Search of Vital Records
_________________________________________________________________________
Date of Event ________________________________________
Place of Birth, Death or Marriage _____________________________
Parent’s name and address:
Father:____________________________________________________
Mother: ___________________________________________________
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Application Made By:
Name
___________________________________________________________
City: _________________________ State ________ Zip ______________
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Mail Copy of Record to:
Name
___________________________________________________________
Address:
________________________________________________________________
City: _____________________________ State ________ Zip:_______________
Relationship to above and reason for request:
_____________________________________________________________________________
Please send this along with the required fee and a copy of your identification (driver's license)
to Bureau County Clerk, 700 South Main Street, Rm. 104, Princeton, IL. 61356
RECORD
REQUESTED:_________________________________________________
(Birth, Death, or Marriage)
Full Name (s) listed on vital record:
(Birth, Death or Marriage date)
(signature)
Address:
_______________________________________________________