HHS-92 (55092) Rev. 5/14
This office has been registering deaths occurring in Nebraska since 1904.
PLEASE TYPE OR PRINT LEGIBLY
Full name of deceased ________________________________________________________________________________
(If female, list married name or any other name(s) decedent may have used)
City or town of death _______________________________________ County of death _____________________________
(If exact place of death is not known, list last known address)
Month, day and year of death ___________________________________________________________________________
(If exact date of death is unknown, list date decedent was last known to be alive or indicate a span of years to search)
How are you related to decedent? ________________________________________________________________________
For what purpose is this record to be used? ________________________________________________________________
___________________________________________________________________________________________________
The information in this section is needed in order to do a thorough search in locating and identifying the requested record:
Year of birth _____________________________________________ Birthplace __________________________________
Spouse’s full name ________________________________________ Home address ______________________________
Father’s full name _____________________________________________________________________________________
Mother’s full name _____________________________________________________________________________________
Funeral Director __________________________________________ City _______________________________________
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.
PLEASE ENCLOSE A PHOTOCOPY OF YOUR PHOTO ID
(i.e., DRIVER’S LICENSE) WHEN MAILING IN THIS REQUEST.
SIGNATURE _____________________________________________
Type or print name ________________________________________
Mailing Address __________________________________________
City, State, Zip ___________________________________________
Daytime Telephone Number _________________________________
Email Address ___________________________________________
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 $16.00 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 DEATH CERTIFICATE
