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Date <br />/S" &piki /Md/ �W�d Address <br />Attachment: certified or authenticated copy of Death Certificate <br />NOTARY <br />State of Nebraska, County of Hall <br />This document was acknowledged before me on the day of June, 2016 <br />(name of Affian <br />By <br />Signature of Notary <br />My commission expires: <br />im iciEtakt. NOM • State of Nebraska <br />RELDA K MILLER (Seal, if any) <br />Kmm. yta Exp. February 19, 2019 <br />cthh <br />201602417 <br />Signature <br />