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Nominee's Address: <br />Nominee's Telephone Number: <br />Name of Nominee for (guardian) of my person; <br />Nominee's Address: <br />Nominee's Telephone Number <br />RELIANCE ON THIS POWER OF ATTORNEY <br />t <br />Any person, including my agent, may rely upon the validity of this power of attorney or a <br />copy of it unless that person knows it has terminated or is invalid. <br />SIGNATURE AND ACKNOWLEDGMENT <br />• <br />Printed Name <br />Address <br />Telephone Number <br />STATE OF NEBRASKA <br />SS: <br />COUNTY OF HALL <br />aie <br />Notary Public <br />My commission expires: ( 2- <br />This document prepared by: <br />Alfred E. Corey III #24095 <br />SHAMBERG, WOLF, McDERMOTT & DEPUE <br />308 N. Locust St., Suite 501 <br />PO Box 460 <br />Grand Island, NE 68802 <br />(308) 384 -1635 <br />Date <br />Carl E. Edberg <br />Tiffany Square Care Center Room 609, 3119 West Faidley <br />Avenue, Grand Island, NE 68803 <br />308 -389 -8697 <br />This document was acknowledged before me on - ?A 2- a l 7 ? by <br />Carl E. Edberg. <br />(Seal, if any) <br />201402055 <br />4'3 <br />X i ' -S eo#Nebrasita <br />ALFRED E. COREY Et <br />My Comer, Bp. Dac.. 8, 2413 <br />