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<br />WHENTHIS COPYCARRES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERWCES
<br />SYSTEM, TTCERn TIES THE BELOW TO BE A TRUE COPY OF THE ORIOIII
<br />THE NEBRASKA HEALTH AND HUMAN SERWCES SYSTEM, WTAL STAI
<br />THE LEGAL DEPOSITORYFOR VITAL RECORDS.
<br />DATE OF ISSUANCE
<br />APR 132004 200406841 ASS
<br />LINCOLN, NEBRASKA HEAI
<br />STATE OF NERRUE - DfiFARREmM OT FmA mAND NUM%YN3
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