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' `' STATE OF NEBRASKA <br />...,�. ,, <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HFALTf�AND.��l�p11�ySE1��/,��ES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THL' M�'BRA�SI�°bEPART.M�AIT C��' H�ALTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY ,FO(�: V�FAL �2$CaO�R�SC; ;': � <br />�. • � , , <br />DATE OF ISSUANCE � ; r _� � '��� ', <br />. S�'A�fL� S: • L�OPf��, l � . .- � <br />'� O1125/2012 � � As�,'SISPAN7'`ST1(fi� RE�IS�RAR ��� � <br />LINCOLN, NEBRASKA � � � � � � � � � ��'���5� T OF_,�1EACT�.A �l� ��� <br />�,� ta �'���,,� e,, �°1 , <br />�'� 4 Y � ti l ° ��," 1 y! � y; `.{...,. <br />P t:: � � � , ;p� � ti . <br />� � �•� <br />�', <br />� �,, ; , ; ., �� ��`�- <br />r � �v <br />�' STATE aF NEBRASItA� • DEPARTNIENT OF HEALT1i AND HUdbAN SERYfCE3 t.! 1 IG ��� � Q <br />t��nc Wam.� , �rR �l a. �. 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DATE SIONED (qo., O�Y.vnk�� 29a T9�E 6P DEAtH y� r Tea.0R0ti0UNCEb oPAD (IAo..�DaY.Yr.►- - 2<d.'19� PRONOItNC�D OFAD <br />��� 01-I2-2012 �: ', .m . �°'� � _ m <br />x+arouroaa�o�mr��(a�h�a+e+an4�.em+.wrouaqaea �� a zee.anaw�.as�.mrmu„�eo�m,�nnopmtonamnaa�ana <br />�� mWmu mi7�b) , O� uttrfler�s.eaeaeWVl#a�wMlduemenwuul�lalatad.f����eTtw� <br />!!�`1-�', � r� ~ � s <br />�����o���„��,� �,:�����,��,� �.,��e� <br />�, <br />�7 �8 '�o O eRO�neGx ';. ❑ t�wawxn+ '�hes : �;, No wea aavua.w. s se. a ao. p v�s, � xo <br />27 .:NMIE,71T1BANDAhURE890RCEi�TIF�RtpN1f�AN�plfl"HiCWtiA8918TA1l�CORbNEA9M1Y814W!14RCOUMYRTTb�tE�11RYPeaPrUit) . �. . . <br />Michael Sullivan, M.D., 6Q9 '0� St;., Autrvra, I�E 68&;i8 <br />tlr. REG187RAR8 BNiNANR6 . 2�+: On7E FILBO ev HE619TRAR (Na.IIaI. Yr.i .. <br />� <br />` � ,lAN 19 z01Z <br />