Fillable Printable Application for Certified Copy of Birth Certificate - Nebaska

Application for Certified Copy of Birth Certificate - Nebaska

HHS-88 (55088) Rev. 5/14

The Ofﬁce of Vital Records has been registering births for persons born in Nebraska since 1904.

PLEASE TYPE OR PRINT LEGIBLY

Full name at birth ____________________________________________________________________________________

(If adopted, list adoptive name)

Month, day, and year of birth ___________________________________________________________________________

City or town of birth _____________________________County of birth __________________________________________

Father’s full name ____________________________________________________________________________________

(If adopted, list adoptive father’s name)

Mother’s full maiden name _____________________________________________________________________________

(If adopted, list adoptive mother’s name)

Is this the record of an adopted person? q Yes q No

For what purpose is this record to be used? ________________________________________________________________

If this is not your record, how are you related to the person named on the record? __________________________________

Delayed Birth Certiﬁcate - Legislation passed in 1941 provides for the ﬁling of delayed birth certiﬁcates for persons who were

born prior to 1904 OR for persons whose births were not recorded at the time of birth.

Is this a delayed birth certiﬁcate? q Yes q No

WARNING: Section 71-649, Nebraska Revised Statutes: It is a felony to obtain, possess, use, sell, furnish, or

attempt to obtain any vital record for purposes of deception.

SIGNATURE OF REQUESTOR ______________________________

Type or print name ________________________________________

Street Address ___________________________________________

City, State, Zip ___________________________________________

Daytime Telephone Number: ________________________________

Email Address: ___________________________________________

Today’s Date _____________________________________________

(Please enclose a photocopy of your photo ID [i.e. current driver’s

license] when mailing in this request).

FOR OFFICE USE ONLY

q Check q MO q Cash

Amount Received ________________________

Date Received __________________________

By Whom Received ______________________

PROOF OF IDENTIFICATION;

DL STATE ID OTHER

______________________________________

Fees are subject to change without notice. Please call our 24-hour

recorded message at (402) 471-2871 to verify fees.

Number of certiﬁed copies________ x $17.00 each = $________ Total

(Please make checks payable to Vital Records)

Mail to: Bring to:

Vital Records Vital Records

PO Box 95065 1033 O Street, Suite 130

Lincoln, NE 68509-5065 Lincoln, NE 68508-3621

(Please enclose a stamped, self-addressed business size envelope.)

APPLICATION FOR CERTIFIED COPY OF BIRTH CERTIFICATE