Application Form For Certified Copy Of Birth Certificate
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1APPLICATION FOR CERTIFIED COPY OF BIRTH CERTIFICATE
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 ______________________________
FOR OFFICE USE ONLY
Type or print name ________________________________________
q Check
q MO
q Cash
Street Address ___________________________________________
Amount Received ________________________
City, State, Zip ___________________________________________
Date Received __________________________
Daytime Telephone Number: ________________________________
By Whom Received ______________________
Email Address: ___________________________________________
PROOF OF IDENTIFICATION;
Today’s Date _____________________________________________
DL
STATE ID
OTHER
______________________________________
(Please enclose a photocopy of your photo ID [i.e. current driver’s
license] when mailing in this request).
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.)
HHS-88 (55088) Rev. 5/14
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