STATE OF NEBRASKA FORM NO. CC 17:5 1/91 NEW Sec. 43-107
NOTICE OF ADOPTION MEDICAL HISTORY
CASE NUMBER
IN THE ________________ COURT OF _____________________________COUNTY, NEBRASKA
IN THE MATTER OF THE ADOPTION OF
NOTICE OF ADOPTION MEDICAL HISTORY
, a minor.
Notice to: Bureau of Vital Statistics P. O. Box 95007 Lincoln, Nebraska 68509-5007 You are advised that on , , I have determined that in the adoption of : (new adoptive name) The medical history of the biological father is unavailable. The medical history of the biological mother is unavailable. This is a step-parent adoption; the court has determined that a medical history is not required in this case.
DATE: BY THE COURT: (Clerk) (seal)