' `' 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$CaO�R�SC; ;': �
<br />�. • � , ,
<br />DATE OF ISSUANCE � ; r _� � '��� ',
<br />. S�'A�fL� S: • L�OPf��, l � . .- �
<br />'� O1125/2012 � � As�,'SISPAN7'`ST1(fi� RE�IS�RAR ��� �
<br />LINCOLN, NEBRASKA � � � � � � � � � ��'���5� T OF_,�1EACT�.A �l� ���
<br />�,� ta �'���,,� e,, �°1 ,
<br />�'� 4 Y � ti l ° ��," 1 y! � y; `.{...,.
<br />P t:: � � � , ;p� � ti .
<br />� � �•�
<br />�',
<br />� �,, ; , ; ., �� ��`�-
<br />r � �v
<br />�' STATE aF NEBRASItA� • DEPARTNIENT OF HEALT1i AND HUdbAN SERYfCE3 t.! 1 IG ��� � Q
<br />t��nc Wam.� , �rR �l a. �. DAre oF o�rrx �xa,DryYu)
<br />AAariatl .I�ns Helivai ' Famele Janua 9.2012 <
<br />.�0. CM AqD BTA'R 6AI iII�TORY, OR F'dR6i3N t�'fUN7i�' OF BfR7H aa�ADEi.rst �Mdq 6b -1lNOER 1 YEh�i� 6w UNQER t f1AY ����. bdTfi � tl1RTH jAlo �Y� Yr.�
<br />�8�.�.@}1i ��. (r�t.l ., hf0& 40.Y8 FWtI� I�ti& _.
<br />' � Nebraska _. -9Z� 86 October 22, g'
<br />- 7.�BORIAl. SFCURITYNUJiBFR t�. PLACB OR DFATFI
<br />'� ' �Q�J-z �H �AL' Q � �..' 9���NmsfnY HomdLTC ���. [� H�piR� F�eplt�l ��.
<br />8a. FACn.rnra+Aeee �� t�aan� y�i. a� �iism�q� 0� I]�• irana
<br />Namifton Manor O ocsa poa,��y�
<br />se: canr ox�waoFa�ani tu�w.mv�� �a aounmvP orxrrr
<br />Aucora,88818 ' Hamliton
<br />m.:�ENCES7ATE �Cd!lI7Y � � ' � BaOrtYOR7'OWN . ..
<br />� . Meb�taska HBmflton Aurora
<br />9tl. STREfff AND NUYBER " Be. APT. N0. � 2W GODB 0& �� uM�
<br />1515 Sth SY. 88818 �] ra ❑ n�
<br />� �a..wuurn�erntusRrr�oFOen�i+ pw�.a Qr�n. t�.���t�ru, �aama uw, am+�pr.�a�.��
<br />� waN.a eu�,�a �� p n�mad. CI u,uo,own RoGert Hell�sri
<br />�, E ' tiiRATH6iC8d!tAl� (FUst. �. ladme� �. Lnf, �1 12�(OTHER9�1MN16 (Flit6 �a.�. MrMb�B�ana�ro)
<br />' � Frank ,k�hnsan ' Genevieve Sullivan
<br />o� taeyeRdau.&�eqr�tCE�c�waneeor.�s�rea. �a;wRO�anrr� ++e.�u►tar�HU*ro�Kr
<br />►� tr+�No,atlM�.) o USa TOriBC? �'
<br />1b: M@71f00 OF O�S[if0l1 � 18�. EIIBALYEl431ONATURB �� 14b.UC�l�E N0. �� .� 1!a DATB Q[u, Da11. Y�l
<br />pamw p� Not EmB$tmed ' Janu 10, 2012
<br />�°�°�"'� p � tsa c�er�ar� ct�ourridr ort an+es i.ocnt� ) cmrrowN ; srnrE
<br />�� ' Q��
<br />Cer�tref Nebreska Crertratiort Serv[ces C3ibtmn Nebr�ska
<br />1Za. FIlNBRAL HOIlBNAmC'ANDIIAIUNQ ADDRE9S I�k �Fm'fa+'R �te) �:.: ��. 12b.ap Cods ��
<br />Ali F'aiqts �'urieral Hcme, 292� S. Locust Steet, GrAntl tslantl,.Nebraska 88801
<br />CAIiS� 4F dEATH Sea lnstruetlon$ artsl:exam I�
<br />'u:vArtTLF+lvHS ��'yww,y�s,m�Po�tdhatlyewn?Brd�W.00lIOTwmr�u(matlamUSC�eamd. �.��� � APPR07I9U1TEWTER1fAL �.;.
<br />nw�N�44r.�wdrf�v�eheuc.m.rnpar.uweaY.lbhm�ru�s�arowran.emrm�e�.:wa.�mrt�mwsnirauu�!fw. -..� �
<br />_�: INA160NT8 CpUBEc � emRtle Ea� � ��.
<br />Idq6WAT8CAU8E(flmd L � �
<br />mq.�Miaaonmua,�g aX � �,�, �yyx,er � ax�
<br />i
<br />W8 TO,fNtAS�ti'�tIS�AUENCB OFi � atatM �
<br />Bs�dly tM eat�rw, 9' �
<br />+4�fK �w�inp toffisomme petetl b � �
<br />w
<br />on�w+l. :::. ;." ClIET4:ORASACOi�iSEQUEN�OF: ..: � �� .':. �� �auatloAeNA �
<br />:, ._. <-; .�...
<br />�n01N6MUNDERLYWOCpU� C� i
<br />� i�swd�v�i�:quitb�tad; DUL'TQ,ORA6ACON�{IENC�.OfY �aaatfa�elh �:
<br />�� n�tl9tig in deetlp).,
<br />' ' ", i
<br />�
<br />: dl �
<br />YO.PIkRTB:OTHERB�@3N�lCANT�COiN�CandldauawWlbutli�gtotlmdw9lGdrtat�DlnfMwdwlyGg:sausspTrw�in?RRTL ..- .. �14.WA8MEDICAL�:OtA�._ �..�.
<br />�fAAONERCONTACiFL? . . .
<br />l'�m�. 1��►���3 ' , �r�. � - �r►� —' ' o;� ,�-�
<br />� 20. PHMALE: 21a. OFOEATH asn.�TRAN�'OR1'AtiON 2�aWA8ANAY7oP8YPEk�ele6?
<br />�, � V1e0nmt�IGdn Pat Yar . ..�ERO N� 3 � �W�pa� ❑ � '
<br />�roe�rql • '
<br />� p�ea�o�� ` ��� Cl�+�ro�s�a� : CIa� �awaeeaurorsvFwceacsavaana�e
<br />� l7Na wa�q we �e.nnu� as a�. �e aaa� ; p ewad. ❑ caea „oe a a.� ❑ vaae�a� ro cor� cau� oF oennrr
<br />0►��nd,cem�a3a.y.mt�earo�.a�n :❑o�.r�so.ary� p �'� ;
<br />� p��wa� R vn�mx� �n. �.e,�
<br />a.; :
<br />> € sxa.oateo�w�ur�rtr�o..u.r.rr.� �a,.tm�em+wrunr �.waa���ruuawainaae.ran,e.va.r.ra�ar.aaaa�u�w�n�s,.es�s�u�r�
<br />� ' ' m '
<br />� red.a�umrnraw4mcr aa..oes���vn�uRYpecu�o
<br />t- �� ��
<br />;.�f4dCATpN:QPINJURY-87AEET6NUYBER.Ap1:�-NO. :�, CRYROYYN��.. � .. .���. ���: STATE�.�.- 7JPCOp� , �..-� �
<br />28a DATE OF OFJITH (Qa �Y� Yd) TOe.6ATE 816pED (qa., Dey, Yr1 21b.TB�E OF DEA'1'R
<br />�' ' ' ' o� 1 c� . ! g' � ttJ!11 '� ' '' m
<br />��.� �Sb. 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 />
|