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<br />WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMANE URI LACES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQ9&Q £UjF*m
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC3E$R9_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />JAN 112000
<br />LINCOLN, NEBRASKA
<br />200001506
<br />met: :-
<br />ASS /STijW,$TA1E W07S _-
<br />HEALTH AND HUAfI4J1l SERIES SYSTEM
<br />Vk
<br />STATE OF NEBRASKA - DEPARTMENT OF NEALTN
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH r�
<br />P1 4681
<br />DECEDENT —NAME F111S AV
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<br />•gip LU 4, 1981
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<br />WHEN TM COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMANE URI LACES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECQ9&Q £UjF*m
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTIC3E$R9_
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS
<br />DATE OF ISSUANCE
<br />JAN 112000
<br />LINCOLN, NEBRASKA
<br />200001506
<br />met: :-
<br />ASS /STijW,$TA1E W07S _-
<br />HEALTH AND HUAfI4J1l SERIES SYSTEM
<br />Vk
<br />STATE OF NEBRASKA - DEPARTMENT OF NEALTN
<br />BUREAU OF VITAL STATISTICS
<br />CERTIFICATE OF DEATH r�
<br />P1 4681
<br />DECEDENT —NAME F111S AV
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<br />GATE OF DEATH (IM.. Day. Yt.)
<br />Rao O1wut Port
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<br />•gip LU 4, 1981
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<br />DATE Of 114M (Me.. Der. Yt /
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<br />NAME Of. SPOUSE ((HIM- iifii. wio.d.w wa—)
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