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NOMINATION OF [CONSERVATOR AND /OR GUARDIAN] (OPTIONAL) <br />If it becomes necessary for a court to appoint a [conservator and/or guardian] of my estate or <br />[guardian] of my person, I nominate the following person(s) for appointment: <br />Name of Nominee for [conservator and/or guardian] of my estate: <br />RICH /9/2.) S. A.JCST/N J'R. <br />Nominee's Address: / 6 G 0 S I S;1, ^4 ° S T A EE T <br />Nominee's Telephone Number: 40.1.— 3 30 —6 9.5 ca., <br />Name of Nominee for [guardian] of my person: R 1 CJ'A R,Q S WEST/N' J, . <br />Nominee's Address: / 6 6 0 S/ 5'"x.'' S T2 EE T <br />Nominee's Telephone Number: t/ (7a- — 3 30 <br />NET T. ORTH <br />Address <br />-3 -0. <br />Phone Number <br />STATE OF NEBRASKA <br />) ss. <br />COUNTY OF HALL ) <br />This document prepared by: <br />Mary J. Livingston <br />Attorney at Law <br />724 W. Koenig <br />P.O. Box 1563 <br />Grand Island, NE 68802 <br />(308)381 -7301 <br />RELIANCE ON THIS POWER OF ATTORNEY <br />Any person, including my agent, may rely upon the validity of this power of attorney or a copy of <br />it unless that person knows it has terminated or is invalid. <br />SIGNATURE AND ACKNOWLEDGMENT <br />Date <br />N • ARY P <br />201306787 <br />This document was acknowledged before me on this )6 4 day of April 2013 by JA ET T. WORTH. <br />