HHS-88 6/21
The Oce 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 Certicate - Legislation passed in 1941 provides for the ling of delayed birth certicates 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 certicate? 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 drivers
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 certied 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 Certied Copy of Birth Certicate