Nebraska Application for Commemorative Certificate of Nonviable Birth (HHS-126)
Official state formStillbirth and pregnancy lossForm HHS-126Free downloadLast verified November 10, 2026
Request for a commemorative certificate for a nonviable birth (pregnancy loss). It goes to the Nebraska Vital Records office with the HHS-124 worksheet.
Who can use this form
- Only the patient of the nonviable birth
What to send with it
- Signed application
- Completed Worksheet for Nonviable Birth Commemorative Certificate (HHS-124), signed by the health care practitioner (per the office's Nonviable Births page)
- Photocopy of a photo ID
- Exact fee and a stamped self-addressed business-size envelope
Where to send it
- Mail to
- Vital Records PO Box 95065 Lincoln, NE 68509-5065
- State fee
- $19.00 per certificate
- Typical processing
- Not provided
- Form revision
- 6/21
- Source
- Official government page