Nebraska Worksheet for Nonviable Birth Commemorative Certificate (HHS-124)
Official state formStillbirth and pregnancy lossForm HHS-124Free downloadLast verified November 10, 2026
Worksheet where a licensed health care practitioner verifies the details of a nonviable birth. It is submitted with the HHS-126 application to the Nebraska Vital Records office.
Who can use this form
- Only the patient of a nonviable birth may request the certificate
- Signed by the licensed health care practitioner or designee (Neb. Rev. Stat. 71-607)
What to send with it
- Submit it with the HHS-126 application
Where to send it
- Mail to
- See the form for where to file it.
- State fee
- Not provided
- Typical processing
- Not provided
- Form revision
- 12/2019
- Source
- Official government page