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4-� <br />OLD AGE ASSISTANCE CERTIFICATE No. ........ .:.202 .............. <br />.....................................................County, Nebraska <br />Name...... knU&..X..B;pQQU...................................................................................................... <br />Age...... 6.6 ........ Address ....... ,Alda.3.1.412.T............................................................................ <br />Amount $.....16...00............ Modified Amount $ ................................ $ ................................ <br />Date........ UY... 5j.i ...........................19.. 6 <br />�.Sigsed) Irl D. T©len <br />This is a tme copy of Certificate originally ... """ .... ..................... Director stance Director of Assistance <br />issued. <br />e .it .....�.......V..M..p4 m.......er <br />............... ............ .............................................. <br />......... Director of Assistance Signature of Applicant, <br />Next Friend or Guardian <br />• <br />