HHS-88 6/21
The Oce 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/Parent name at birth __________________________________________________________________________________
(If adopted, list adoptive father’s/parent’s name)
Mother/Parent name at birth _________________________________________________________________________________
(If adopted, list adoptive mother’s/parent’s name)
Is this the record of an adopted person? o Yes o 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? _______________________________________
(If this is not yourself or your child’s record, then proof of relationship will need to be provided)
Delayed Birth Certicate - Legislation passed in 1941 provides for the ling of delayed birth certicates 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 certicate? o Yes o 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).
(Please make checks payable to Vital Records)
FOR OFFICE USE ONLY
o Check o MO o Cash
Amount Received ___________________________
Date Received _____________________________
By Whom Received _________________________
PROOF OF IDENTIFICATION;
DL STATE ID OTHER
_________________________________________
Only exact amount will be accepted.
Number of certied copies________ x $17.00 each = $_________ Total
Mail to:
Vital Records
PO Box 95065
Lincoln, NE 68509-5065
(Please enclose a stamped, self-addressed business size envelope)
Nebraska Department of Health and Human Services
Application for Certied Copy of Birth Certicate
