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6/20/2013 12:11:32 PM
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011-593
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111 <br />PRS- '.A(vSl REV 4-37 <br />STATE OF NEBRASKA <br />- <br />DEPARTMENT OF PUBLIC HEALTH. <br />EDUCATION AND WELFARE <br />DEEARYAL.NT OF REALT9 <br />Bureau of T'iW CygtaUxtics <br />'STA7'9 <br />((��� `� <br />2 % j$3 <br />BIRTH NO, 126....... <br />OF VLATH <br />FILL NO, V L <br />1 KAU DI D[ATr <br />f1N rr. Hall <br />IT•rt ::ebraska <br />♦ CO3— Hall <br />M1. CITY 11.11 111 L-11pM <br />E. <br />t C TY .C.W W L0..T41 <br />! . r , mu-) <br />Grand Inland <br />Cairo <br />i t lurt W it -I . <br />nnT .or ess <br />St Francis Ho <br />llwr+ir�/ <br />a <br />= <br />_ 1t1 no <br />o1 Fbr <br />f <br />vow t.✓ <br />f o•R .Yw► Do 141 <br />D"Mil <br />me <br />J <br />1 <br />WIDGWtD DIYCMC[D �J1 <br />i <br />t.•IVwa...�iM.,...�xal <br />Fc <br />faming Hall Count Nal1r. <br />U 9, A <br />t , f•Tx[I f MAY(' <br />17 ►. rpT.,f1 t Y•IJt• NAM[ it .•W D/ MIRIAM A — <br />Ire ..d..... „ 1...✓. u. r....w <br />✓n <br />I I I Mrn. <br />I��i1R�e /,�y1ThK Y .•I. <br />IA11T 1 D(•ir�Y•S UuYD Il' /�� ����% <br />In..•I a+ <br />�)� <br />cen(Yie.f. r /.D►. j DAD rCs cei <br />.6.w ow♦r�.4 Ir( <br />. rriti rV . W t.,t r0 (tl <br />( Oi nMr "rur <br />Y <br />.IIC <br />❑ ❑ ❑ <br />i <br />� <br />IMINI I. <br />F r. <br />E. <br />■.ILL .1 C] WT .",If ❑ Jr...• 'I. ad w. <br />. .T Zvi <br />! . r , mu-) <br />•n - f.�la�RA1RA► <br />J]] rarul I�l arvi IQwhrf rka <br />`f�' DI�MAI��(NQITYMt ADDI[y <br />JAL 0 1962€ ns n- 3ondemann Gram Sn7 end, <br />r Y i <br />�� S 3 <br />
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