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OF AN ORIGINAL <br />DRrl T EABOVETO BE A TRUE COPY <br />IPSRTII IC IVE WITH THE STATE DEPARTMENT OF HEALTH, <br />1URF,A VI L,• ATISTICS, WHICH IS THE LEGAL DEPOSITORY <br />OJRD <br />� ». ' DIRECTpR 0 VITAL STATIST&fAND ASSISTANT STATE REGISTRAR <br />LINCOLN, NEBRASKA <br />i!— !O <br />a <br />j <br />r <br />Mate of Nebraska <br />l County er <br />Lici1 4 _ r3,CL, Y< > ss <br />& .':r.• .!fir, rj a >3L°fi <br />for rec^ g `:,Y if <br />e of <br />a1 <br />i <br />and <br />t'cti " <br />--------- of <br />_ <br />Register of Heeds <br />By------ --=----- - - - - -- - - - - -- <br />? Y <br />Fees Deputy <br />$o_?� - ----- <br />