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Please Note: The Fee is $15.00 for the first certifed copy of each record and $9.00 for each additional certifed copy of the same record. There is a $15.00 search fee for records searched, yet not located. PLEASE MAKE CHECK PAYABLE TO: McLean County Clerk Application for Search of Birth Record Files of Deceased Person This application form is prescribed and furnished by the Illinois Department of Public Health as set forth in 410 ILCCS 535/25.1 1. Name at Birth 2. Place of Birth 3. Date of Birth 4. Father's Full Name 5. Mother's Full Name First Middle Last Hospital City or Town County Month Year Day Sex Male Birth Number (If Known) First Middle Last First Middle Last Section B - Death Information Section C - Applicant Information 1. 4. 5. 2. 3. Full Legal Name At Death (First, Middle, Last) For Female Decendents, Maiden Surname Date of Death (Month/Day/Year) Place of Death (City, State) Relationship to Decendent 1. 4. 5. 2. 3. Name (First, Middle, Last) Street Address City, State, Zip Social Security Number Driver's License Number/State Section A - Birth Information I affirm under the penalties of perjury, that the representations made on this application are true to the best of my knowledge and belief. Date: Work Telephone: Home Telephone: Written Signature: ( ) ( ) You Must Include Proof of Death PLEASE MAKE CHECK PAYABLE TO: McLean County Clerk Female Mother's Maiden Surname ON BIRTH RECORDS 75 YEARS AND UNDER A COPY OF A SIGNATURE ID IS REQUIRED WITH ALL MAIL REQUESTS (The extension of the expiration date must be copied if applicable) Kathy Michael, County Clerk Government Center 115 E Washington Street, Room 102 PO Box 2400 Bloomington IL 61702-2400 Phone: (309) 888-5190 Fax: (309) 888-5932 E-Mail: [EMAIL REDACTED] *Birth records are available from 1860*