Department of Vital Records:

I, ______________________________________________________ authorize USABirthCertificateBureau.com to obtain my certified birth certificate for me from the state of Nebraska. I also authorize USABirthCertificateBureau.com to discuss the status of my birth certificate request if needed.

Name and Address of birth certificate Applicant:

Name: ______________________________________________________

Address: ____________________________________________________

City:__________________________ State: _________ Zip: ___________

Signature of certificate holder: __________________________________

Date: _______________________

 

Notary Stamp:

 

 

Notary Signature: ___________________________________

 

This Form Must Be Notarized