Form Hhs-92 - Application For Certified Copy Of Death Certificate
Download a blank fillable Form Hhs-92 - Application For Certified Copy Of Death Certificate in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Hhs-92 - Application For Certified Copy Of Death Certificate with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1APPLICATION FOR CERTIFIED COPY OF DEATH CERTIFICATE
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
FOR OFFICE USE ONLY
(i.e., DRIVER’S LICENSE) WHEN MAILING IN THIS REQUEST.
q Check
q MO
q Cash
SIGNATURE _____________________________________________
Amount Received ________________________
Type or print name ________________________________________
Date Received __________________________
By Whom Received ______________________
Mailing Address __________________________________________
PROOF OF IDENTIFICATION;
City, State, Zip ___________________________________________
DL
STATE ID
OTHER
______________________________________
Daytime Telephone Number _________________________________
Email Address ___________________________________________
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.)
HHS-92 (55092) Rev. 5/14
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business