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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION -WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE] N
<br />q r����?� 1�CANL�Y_�cZ'OOPER
<br />NOV 1 9 ZOOI y AS$14TANT16171T EGJS:T)"R
<br />LINCOLN, NEBRASKA HEALTH ANb H(*AN -SEJq II MMM
<br />Y-
<br />200112025 - -
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<br />County,
<br />Nebraska.
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION -WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS.
<br />DATE OF ISSUANCE] N
<br />q r����?� 1�CANL�Y_�cZ'OOPER
<br />NOV 1 9 ZOOI y AS$14TANT16171T EGJS:T)"R
<br />LINCOLN, NEBRASKA HEALTH ANb H(*AN -SEJq II MMM
<br />Y-
<br />200112025 - -
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<br />nf% r►cn-sn
<br />�rMlt >• N1pf = V awmv :Pt0o1 t rytw w . ✓.. .w.. v �..w .M1t w vow
<br />W.04 � liaaAra airs t AZ ! k
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<br />8t. Francis Medical
<br />Center
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<br />❑.,.
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<br />M 0"TV OP DEATH
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<br />F "' "'
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<br />tq KNO OF El iWEl6 P+OUST111.
<br />15 EDVCATIM 1 A
<br />♦MNrtwliAter
<br />Ivisor
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<br />AOOMS IS70"T01111FONOpriOAT00%VArtz"
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<br />�► DATI[OWIED ".OW Yrl ?A
<br />T.E OF DEATH 2tt PRONOUNCED DEAD Mo OPII nl 211 R10NOUNCEO DEAD IrAH+I
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<br />L"' ❑ YES 7O ❑ YES ND
<br />E1, NAME ANO ADDRESS OP CEaTFIER IPHrS W COIAINf R S PHYS AN OR COUNTY ATTOA NE rI , T,p a Pw0
<br />nA 1„t:l aU _ NF. b8803
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