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m <br />n <br />r) (1) <br />Ili. MMOR FMM= op OpZ"MON <br />m <br />C::) <br />X > <br />m Ln <br />c:> <br />"a xa;,!, <br />121L Pg�9== (a !a or abo <br />POO^ bft. @M <br />fin <br />< o <br />C:) <br />OM <br />U) <br />C:) <br />Co <br />and that death occurred at/,O <br />4 <br />(Dew J5tuts) <br />I u A <br />Na. VURIA14 0 s 2 M A- 24L!A24c. N Ap OF <br />MN. ' <br />G* <br />F-A <br />> <br />r- <br />4n <br />WHEN 110S COPY CAMMS THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAAF SERVICES <br />SYSTEM, ff CERTIFIES TPff BELOW TO BE A TRUE COPY OF THE ORIGINAL REQMD -6N.AiE-wTH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTMOEMM, kargi-m <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. <br />200107128 DATE OF ISSUANCE <br />JUN 2 2 2001 ASSISTANUSTATEREGIStOM <br />LINCOLN, NEBRASKA HEALTH AND HUMMq IM 4! Tkik <br />V`� <br />No.. <br />16 07M <br />L an W. <br />4L WANNOW - 11 <br />3 OF -'IL <br />M, t <br />1LTm8 DECEASED mv DUV. <br />uakw")Il( <br />OF DMU <br />D <br />DU <br />ATOM Cpl <br />01 <br />ww w 'A <br />INiA n <br />MZDXWL <br />OE = <br />coimON <br />M <br />WWAA49n <br />-Not <br />Ili. MMOR FMM= op OpZ"MON <br />4 <br />007920"' <br />d> <br />c:> <br />"a xa;,!, <br />121L Pg�9== (a !a or abo <br />POO^ bft. @M <br />cr) <br />< o <br />C:) <br />—1 <br />CD <br />X6 Not MMU at Work 0 <br />C:) <br />=- <br />and that death occurred at/,O <br />4 <br />(Dew J5tuts) <br />I u A <br />Na. VURIA14 0 s 2 M A- 24L!A24c. N Ap OF <br />MN. ' <br />> <br />r- <br />C4 <br />P-0. <br />CO <br />CD <br />O <br />-Not <br />Ili. MMOR FMM= op OpZ"MON <br />4 <br />007920"' <br />VWX <br />"a xa;,!, <br />121L Pg�9== (a !a or abo <br />POO^ bft. @M <br />n& TnM (Mona)' (D07) <br />II <br />(y"r) 210. om <br />11wnhudwh " we r k 0 <br />X6 Not MMU at Work 0 <br />2LZ hereby certify at Z attended Abe deceased <br />j <br />RP <br />and that death occurred at/,O <br />4 <br />(Dew J5tuts) <br />I u A <br />Na. VURIA14 0 s 2 M A- 24L!A24c. N Ap OF <br />MN. ' <br />- ------ --- I - - --------- Tr <br />W, <br />w <br />13 <br />w '01'z <br />1>4:'010M 614111110974317AW <br />COMMON& <br />CRUMAM "tL <br />U& MTZ OF OPMA- <br />Ili. MMOR FMM= op OpZ"MON <br />TIONI <br />212- WCMAM (SPOWY) <br />121L Pg�9== (a !a or abo <br />POO^ bft. @M <br />n& TnM (Mona)' (D07) <br />II <br />(y"r) 210. om <br />11wnhudwh " we r k 0 <br />X6 Not MMU at Work 0 <br />2LZ hereby certify at Z attended Abe deceased <br />j <br />ceased alive on_ M/f-, <br />and that death occurred at/,O <br />TLMS <br />J <br />(Dew J5tuts) <br />I u A <br />Na. VURIA14 0 s 2 M A- 24L!A24c. N Ap OF <br />MN. ' <br />�NF lr� <br />LAW <br />OF WBAT <br />ImUr"d <br />Omw Brewwta <br />nr <br />4V. <br />20. AUTOPSY? <br />Y- 0 NO 1w <br />21c. ACM0211-T-60m) RUBAL) (COUNTY) (STATE) <br />Xu- HOW DID DInMy OCMRT <br />from the <br />" mat I last saw do. <br />PTih ' he stated above. <br />=e. DATE 81"W <br />to or ty) <br />D -1 <br />LEGAL- Lot One (1), Block Two (2), Better Homes Subdivision to the city of <br />Grand Island, Hall County, Nebraska excepting a tract of land more particularly <br />described in Warranty Deed filed in Book 164, Page 131. <br />