Consent by mother of illegitimate child. I, _________, being duly sworn on oath, state that I am the mother of _________, born _________, _________[date] at _________ —.m. at the _________ hospital in _________, _________; that the child is illegitimate and the father of the child is unknown. I do hereby give and grant unto _________ and _________ full care, custody and control of the child and hereby expressly waive all further notice and consent that the child be adopted by _________ and _________, and I hereby authorize and direct the _________ hospital at _________, _________ to release and deliver the child to _________ and _________. Dated at _________, _________[date]. _________ this _________ day of _________,
[Signature] Witness Address _________ _________
[Acknowledgment, if required.]