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<br />STATE OF NEBRASKA
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<br />rWilfAfTHISCOPY CARRIES THE RAISED SEAL OF STATE OF NEBRASKA, 177:CERTIFIES THE DOCUMENT BELOW TO
<br />P.gA.t,00kope...yopirOgi::9R/GloyAt. RECORD ON FILE WITHirfiE NEBRASKA' DEPARTMENT OF HEALTH AND
<br />iiumArtgEkviees;,:tfit4L'RECORDS OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITALRECORDS
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<br />LINCOLN, NEBRASKA
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<br />„WA/IC"? r44.4.10141,11,
<br />SARAH BOHNENKAMP
<br />ASSISTANT STATE REGISTRAR
<br />DEPARTMENT OF HEALTH
<br />AND HUMAN SERVICES
<br />STATE OF NEBRASKA- DEPIARTMENT OF HEALTH AND HUVIAN SERVICES FINANCE AND SUPPO Q 2 0 317: . .:-.:: . .....:.::: :
<br />CERTIFICATE OF DEATil
<br />..1. 050 EDE pri.s.snote !first, ki ;Jew, Laaf, SarEil 2: 3 EX a• DATE 7:rDiRl' Oh- Civt Yil '... '
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<br />Richard R Jensen ale Januszy 16.2009 .1
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