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To Be CompletedNerified by: FUNERAL DIRECTOR <br />1. DECEDENTS-NAME (First, Middle, Last, Suffix) T <br />(' To Be Completed by: CERTIFIER <br />STATE OF NEBRASKA <br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMENT OF HE.ALTKANIA,WMAN SERVICES, IT CERTIFIES <br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE SKx60 P,AETA lye' OF HEALTH AND <br />HUMAN SERVICES, VITAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY'FOR VITAL RECORD ;t. ; ? <br />DATE OF ISSUANCE <br />JUL 2 8 2014 <br />KA HUMAN SERVICES t <br />STATE OF NEBRASKA - DEPARTMENT OF HEALTH AND HU &R' Jdes, - <br />CERTIFICA <br />• <br />STANLEY S. COOPER, c <br />ASSISTANT $Ti4TE R G1STRAR <br />DEPARTMENT C PHEALTH AND <br />201505758 <br />7 <br />