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STATE OF NEBRASKA—DEPARTMENT OF HEALTH 71 12036 <br /> Bureau of Vital Statistics x126- <br /> CERTIFICATE OF LIVE BIRTH "`Lra .a " ,IN„NYN.N <br /> CHILD- NAME FIRST tome EAST - DATE Of EARTH“4"Mm,.n.Tun HOUR <br /> T. Michael Franz Wieck h. June 19, 1971 n 8:44an <br /> SEX THIS BIRTH—SINmq n+IN,nom,Crc. IF NOT SINGLE EARTH—nom Nn;stooNO, COUNTY OF BIRTH <br /> I SPECIES TH1110,ETC.IAenPY) <br /> ,. Male E.. Single a. ,.. Merrick <br /> CITY,TOWN,OR LOCATION OF BIRTH INSIDE CITY LIMITS HOSPITAL—NAME IN NOT IN HOIFnM,GIVE STEM AND NDM.US I <br /> 'SPECIFY VII ON NCH <br /> a Central City, Nebraska k. Yes ,..Litzenberg Memorial County, Central City, Nebr, <br /> ,MOTHER—MAIDEN NAME mar MIDDLE LAST AGE IAT TIME of STATE OF BIRTH I IF NOT IN LS...,NAME COVNIEV I <br /> THO SI.m r <br /> «. Rowwitha Paula Schupferling a. 18 e. Germany <br /> RESIDENCE—STATE COUNTY CITY,TOWN,OR LOCATION INSIDE CITY LIMITS STREET AND NUMBER _ <br /> 'PICOT YES ON NOI <br /> FE. Nebraska N. Merrick T.. Central City, NE FR Yes EE. 211 C Street <br /> FATHER—NAME FMS! DIDDLE LAST AGE HAT TIME OF STATE OF BIRTH III NOT IN U.S.A.,NANE COINTEY I <br /> THIS SHUN/ <br /> E.. Michel - %+esslie Wieck e. 23 It Nebraska <br /> INFORMANT—NAME OR SIGNATURE RELATION TO CHILD <br /> S. Michel Wieck u. Father <br /> i'I Mn,Y ma ME•wvE Nu m LAVE TIN PLACE AND EMI .4 me IS DATE SIGNED IMONm,DAY,reu I ATTENDANT—MAD.,D.o.,omn <br /> l SIAM COM.wve. E I I SPECIFY I <br /> 1«.SIGNATURE \ it 6-21-71 ec M.D. <br />• <br /> -CERTIFIER—NAME I TYN O.PRINT I MAILING ADDRESS I SnIET OP R.F.D.HO.,CIlT OE TOWN,STATE,SO I <br /> Z.....' <br /> IN. E.T. Zikmund M . la. Central City Nebraska 68826 <br /> REGISTRAR—S /WWy/ DATE RECEIVED BY LOCAL REGISTRAR <br /> {iiD!e 1 oMN DAY YEAS <br /> Ilk • <br /> WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA <br /> STATE DEPARTMENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE <br /> • <br /> A TRUE COPY OF AN ORIGINAL RECORD ON FILE WITH-THE STATE - <br /> DEPARTMENT OF HEALTH, BUREAU •OF VITAL STATISTICS , WHICH <br /> IS THE LEGAL DEPOSITORY FOR VITAL RECORDS . <br /> j' .4... .;,. <br /> DIRECTOR OF VITAL 'STATISTICS AND ASSISTANT STATE REGISTRAR • <br /> LINCOLN, NEBRASKA lssued August 13, 1975 • <br />, <br />