Proviso Township Clerk | Foster G. McGaw – Loyola Hospital | Birth Certificate Request

Vital Records Department 4565 Harrison St., Hillside, IL. 60162 Phone: (708) 449-4303 – Website: provisotownship.gov

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NAME AT BIRTH:

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DATE OF BIRTH:

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PLACE OF BIRTH: Foster G. McGaw - (Loyola Hospital)

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MOTHER'S NAME:

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FATHER'S NAME:

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REQUESTOR (legal parent or guardian):

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MAILING ADDRESS:

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PLEASE CONFIRM MAILING ADDRESS:

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PHONE NUMBER:

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Driver's License (Front)

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UNDER ILLINOIS LAW {410 ILCS 535/25 9 (4) (B)}, A CERTIFIED COPY OF A BIRTH CERTIFICATE IS ONLY AVAILABLE TO PERSONS WITH A “DIRECT AND TANGIBLE INTEREST” IN THE RECORD, SUCH AS THE INDIVIDUAL, A PARENT, A GUARDIAN, OR A LEGAL REPRESENTATIVE. ANY PERSON WHO WILLINGLY AND KNOWINGLY USES OR ATTEMPTS TO USE ANY CERTIFICATE FOR OTHER PURPOSES IS GUILTY OF A CLASS 4 FELONY [410 ILCS 535/27 (C) (F)], PUNISHABLE BY UP TO THREE YEARS IN PRISON.

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By typing your name below, the applicant agrees to be bound by the terms and conditions described in this application. Failure to comply with these terms may result in the rejection of the application. The electronic signature is equivalent to an original signature and constitutes proof of their consent to be bound by these terms.

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PRICE:

FIRST CERTIFIED BIRTH CERTIFICATE: $11.00
EACH ADDITIONAL: $2.00

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Proviso Township Clerk | Foster G. McGaw – Loyola Hospital | Birth Certificate Request

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