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<br /> �ACCIDfIVT,SU1ClOE�,NOMICIDE, A F INIUNY �rO..tw,o.r,.e.i NOVN � � MOW IN/URT OCCURRED' � � u+�Or�r u• ���O�r.i.'�,rr<w�a
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<br /> EM6AtMER SIGNAl�1Rf{UCENSE NO � �✓. REGISTRAR—S�GNAIVrtF � o��f�ecfivt0�Y loC�l�EG�;fAw• .
<br /> 756.
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<br /> � �,. �" ,,,.WHEN;THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA
<br /> ` bSTA�T�,�DEPARTPIENT OF HEALTH, IT CERTIFIES THE ABOVE TO BE
<br /> `rS Ar'�I�„�I-E' COPY OF AN ORIGINAL RECORD ON FILE WITH THE STATE
<br /> �'.�,,�" "p.E`��$TMENT OF HEALTH, Bi7REAU OF VITAL STATISTICS, WHICH
<br /> ✓� " �" .s:THE LEGAL DEPOSITORY FOR VITAL RECORDS.
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<br /> , ; DIRECTUR OF VITAL STATISTICS AND ASSISTANT STATE REGISTRAR
<br /> LINCOLN, NEBRASKA issued August 18, 1977
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