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Last modified
6/20/2013 11:18:55 AM
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6/20/2013 10:40:52 AM
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011-302
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TH, C� R FI�S F.�.�iO�&.TO fib A TRUE COPY OF AN ORIGINAL <br />C !#'I; '1E,A F %%V•CTH TH8 STATE DEPARTMENT OF HEALTH, <br />BURE�tiiJ C� V3�TAA3WrAJ i`ISTJC,S. WHICH,IS THE LEGAL DEPOSITORY <br />FOR VI-?A[, 2F.e <br />DIRECTOR OP IY TAL S Aii iK5 AND ASSISTANT STATE REGISTRAR <br />LINCOLN. NEBRASKA. <br />12 <br />E[ate Ncbr,zka i <br />.�: cf . ti <br />ss <br />fcr cz .,f of <br />,i <br />ca-V cf .' <br />January___- B_b.3' -_ at________ <br />a'c ?a:> wLI:i _ 39 _. M' ;rtes P. 74. <br />�a _ _ cf <br />-- <br />T - <br />---- --- • - - --- --------- -- ----�. <br />$ 5 -- <br />J <br />w. <br />t�Gitna VasJ, e <br />
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