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<br /> <br />tot SaAlnc punU"'V1. .."l .....1(' L:nlf,Q".. \.~"u"nl.....1 \.udc-; <br /> <br />1. Dt-bl(H"'(t.)'(LII,t. Nanw- f.Not) and Addl"t1...(t':li): <br />C'rand Island Regcl.cy Retirement <br />803 Alpha Street <br />Grand Island, NE 68803 <br /> <br />Sueial Security No. __~~~~~ <br /> <br />~i-- <br /> <br />. \~....ltr.U...i,_ <br /> <br />I :,.Itt"t,'" t'u~~.ft1onj" <br />7. S~\I,fd ,.,...,(ml: Namt(t' af'd 'AddrnM't'$): <br />Hospital Authority No. 1 of Hall <br />County. Nebraska <br />306 No. Bank Building <br />Grand Island, NE 68802 <br /> <br />4. For Yilinc Offitn: umr. Dati. <br />:-'0.. Faint Offin <br /> <br />~. Th~ Fanan.ci... SUI~n. !Aven th~ Foll~ihl T,p~ ~.. hC'tfll,J 11).' PhlpCTl',: <br /> <br />FM"'"ll.D. No. ___.___ <br /> <br />IS21108~;:O <br /> <br />See Exhibit "A" attached hereto. <br /> <br />I&J ....0<<<<10- <br /> <br />D\."KfjpC~ o! Rot..1 EAI...I~ <br /> <br />IXJ "..,d",.. of ,he Con a'....,,' or< AI", c.....rd, <br /> <br />See Exhibit "B-l" attached hereto. <br /> <br />8. Som<{,) of <br />ll.<"....d <br />Ow.....,,,, <br /> <br />-- <br />10. Th. UaU"Jnt"~1 1. 1IIt'd without rhf" df'b!(III""' licna~urf" Co pt'Tftt"l 111 If'nlrity .nlfrO' in coIla1""_' <br />(du.cil 00 ir iO~ <br /> <br />o ..Jrf'.d,. tUbj'Kf 10 Ii IKurit)' ~nttft1.i in Jln(1lhf'f jutitdi(lio" whl:'n it Wat btout:hl ..\10 thtt. t'--U'. Of <br /> <br />o __hkh . w::-rOf;t=rd.. Qi' thf' f(,jl1o...inc d~(ribt-:d ~ri..in6i' c"lblt'nl "..hich .a, pt'trt'Citd: <br /> <br /> <br />G~! REGENCY RETIREMENT <br /> <br />By . ~~. ---- <br />Si.naturr(.) 01 D.b'a,(.) <br /> <br />FORM 801 <br /> <br />.~:I <br /> <br />. <br /> <br />6. lXJ T. \or lI..~d.rd in 11..01 <br />r",..... Monp... lI.....ordo <br /> <br />~.G,.:.t..,~ T9',,'nrl 11"8""'("Y 11.....,,...m.....t <br /> <br /> <br />... A..i.....i.. 01 Sr.......! ro", ond Add,nt{..l <br />Douglas County Bank & T~ust <br />Co., TlUS tee <br />6015 Northwest Radial Highway <br />Omaha. NE 68104 <br />r:oTpn,.~t"P TTtlo::t' nppt'. <br />AUTHORITY"NO. 1 OF HALL <br />EB /' <br /> <br /> <br />.....t' <br /> <br />.. <br /> <br />-.... <br /> <br />