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WHEN THIS COPYCARRES THE RAISED SEAL OF
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<br />THE LEGAL DEPOWTORYFOR VITAL RECORDS
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<br />WHEN THIS COPYCARRES THE RAISED SEAL OF
<br />SYSTEM, ff1= 3THEBELOWTO BEA TRW
<br />THE NEBRASKA HEALTH AND NNMAN SERVICE•
<br />THE LEGAL DEPOWTORYFOR VITAL RECORDS
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<br />DATE OF ISSUANCE
<br />200401211 1/14/2004
<br />LINCOLN, NEBRASKA HE
<br />STATE OF NEBRAS%A- DEFAATA®RT OF Im LLTH
<br />WRAL ST
<br />00116
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<br />FKeith
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<br />HGSmk ❑ I.FU1w STIE_R. ❑ FA,FYXe•,.
<br />485 -36 -6932
<br />❑ FT.II X ® RNA.
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<br />518µE 9th St., Grand Island, Nebraska 68801
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<br />1. OATE FILED 61 PEO11 1. -1 wl
<br />F.A.T. INA
<br />JAN 12 2004
<br />
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