Download Application For Certified Copy Of Divorce Certificate for Free

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HHS-95 (55097) 6/14
This office has been registering dissolutions of marriage (divorces) occurring in Nebraska since 1909. For records occurring
prior to 1909, or if you wish to obtain the divorce decree, contact the District Court in the county where the divorce was
granted.)
PLEASE TYPE OR PRINT LEGIBLY
Full name of husband _________________________________________________________________________________
Full name of wife _____________________________________________________________________________________
City or county where granted ____________________________________________________________________________
Month, day, and year granted ___________________________________________________________________________
For what purpose is this record to be used? ________________________________________________________________
If this is not your divorce certificate, how are you related to the person listed on the record? __________________________
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 _____________________________________________
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 driver’s
license) when mailing in this request.
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 DISSOLUTION
OF MARRIAGE (DIVORCE) CERTIFICATE
Application For Certified Copy Of Divorce Certificate
source: dhhs.ne.gov
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