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' STATE OF NEBRASKA
<br />j WHEN THIS COPY C,4RRIES THE RAISED SEAL OF THE NEBRASKA DEPARTME'NT Q!� HEALTl�,���1�NF�Af�S IT CFRTIFIES
<br />THE BELQW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE tVEBRA�l�# D����'IQ��fi f�O�F'J-(EALTFF AND
<br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSfTQlR3�fiQR 1/�A;f f�.DS •�- �, �;
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<br />i 7�NAlAE.ttTLEANOADDRESSOfCEATIFlER(PHYSIqaN.00RO1�R'SPHY8ICIANORG�lNiYATTbflNEYI fij�pso�PniM)
<br />Will�am J. �andiss, M:D. 2944 W'. Fafd.Ze Av,� Gr�nd IsI. nd brask
<br />� � 480.DATE FILED BY REfi1STHAA (bo., Dey, Y�.)
<br />28a REGISTAIW8SI0NATURE
<br />�` � AUG � 6 2006
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