Free Notice of Adoption -- Medical History, CC 17:5 - Nebraska


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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)