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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS DATE OF ISSUANCE JUL 0 6 2004 200406965 ASSISTANT IAN�LEYS. COOPER STATE REGISTRAR LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM STATE OF IEDRASKA- DEPAIUMM OF IEALTH AND HUMAN SMVXMS FDW4CE AND StPPM CERTWICATE O DEATH 02 07483 ' • NAME FIRST MIDDLE LAST 2 SEX '3 CATS DF DEATH ;ANA a1 Y,y Dobres L Lacbuit lFemale ; JEW 18, 2M ,TATE OF BIRTH NAM n US A. NMII CWIFT j 150 AGE . LAM i;;;;Y 1N/0ER / YEAR I UNDER T DAY 6 DATE OF 611TH Ay 1/1 DAr yn Platte Center, Nebraska SAS -28 -6177 • nndmpftsmgmseero St. Francis Medical Center Sl i LAL_ ❑ nPiMMI ER OL%WWW CDOA ❑ RIPSOW t ❑ O,1r ;soiiw r Grand island ; Yes [� No ❑ � no 98 RES --r _ STATE 96 COUNTY I 9c CITY. TOWk OR LOCATION 1 90 STREET AND Al ONQ --44 -V ZV .I'W 9e AI$IDE CRY IYTS Nebraska Hall i Grand Island 107 W. Mhton Avenue 6MI Ys Kj NI ❑ 10 PACE - leg..*vm Slack. AMWCW Fldan 11 ANCESTRV,eq %Ww M•ccan.GWnW_Wi 112. MARRED ❑ *CDOV*D T3 NAME OF SPOUSE •P lalr o.e RWTi AMW ar i iSocbi White i ISo•CM1 American 1 NEYEfi � OTIORCED � Terry Lack" ( 4MIRRIEO Lam_ 144 USUALOCCUPATION tGne (ur10d•aeIi JIXI!yrng nl`9 146 KIND OF BUSINESS M4OUSTFi'Y i.1i EDUC.ATiDN i50sGr 0.II. !6gh•�QfAOl con+Wrq 0/r614my Ae~YM*mdj �k• -nOW aS•twoa•Y -0 '2; Cosmetologist Owner Beauty Salon 12 16 FATHER -NAME FFST MIDDLE LIST it? MOTHER FW,7 MiWLL MAIck QmadaF Minnie - - - - - - - - -- - - -- -- -- --- fYesroOrIIIC{ � tIYNlS {T�NrA1106a1e5 dspr.:t•{ No Terry Lachnit 19b INFORMANT MAXJ%ADDRESS STREET ORRRFO WJ ,CM OR TCw, STATE 21P, 107 W. Ashton Avenue, Grand Island, Nebraska (M91 20 IsER• TUBE S Lcq4SF NO w M 916 METi4M CF D SPO'5ITin ;216 DATE 2tc CEM.EIERYORCREMAT;)FT. NAME af�l9 !J #1871 ❑ 751. June 28, 2802 JJuiv. Of NE Anatemie:l Beard FU MAL HOPE NAME rT . 21C CEWERY OP. CREAFAT'.Y LOCATION .iTI y TOVO4 STATE All Faiths Funeral Hoare ❑ — Q c-a Omaha, Nebraska 220 FUNERAL HOVE ADDRESS :STREET OR RF D NO CITY OP'O* N STATE. 2:31 -- 2929 South Locust Street, Grand Island, Nebraska 68881 23 PART IM NTMEDIATE CAUSE +EER ONLY ONE CAUSE PER LIB¢ FOP 3, -W AND iCN Ilea' e! s] bONR e natural causes unknown 1UE TO, AS A CONSEOUENCE OF ,.,r., y Dem en order arc �_ — mI DUE TO OR AS A CONSFOVENC'E OF —" rAe..a+ OeNeec ; ImNS !c1 PART OTHER SIGNF10AM CONDITIONS COneians e0rrmr,,rr3 •c ♦ x6n tAt •rcN rowel 0XC 0 F sEMALE was THERC A AU'TON'S" 25 WAS CASE REFERF *D TO MEDICAL M # PgF.C.NMNCY F4 THE -AST ? M.;?4Tr5' EIMAMINER OF OCROW_F' Ayr_;::tr Yes I Ne ❑ +rz L 1 No ®I Ves Mu 1 266 26b DATE OF WURY :W far Y.; 26, ++OIJP OF ftAIPY 26c DE _:< R6E HOW Il v, C, DACCNAT!Ml O U'IOHd" "Mtl j . S SurcYx. P.ro q 26e MNjURV AT wc.RK m OF Ian1RY . N I•c a W— vr... � � e01+lQT9 nt S[Ir/rl .,:{ +OCA:K;N STREE' RFD FND ::i1 -. OR TOl91. _TXIE j H0^6cd• r".v e.1 Yes ❑ NO ❑ 27a DATE OF DEATH rRlu oar Y.; — ; 24. JA'E uVED W :An 'June 27, 2002 4:22 pm. �i DMATE SIGNED Ato C,n + 27: TIW_ OF DEATr ^� ' ' i 2ec %•Paih:,MiFCEt ;.•f ay ►t aw Y. ;Mn �ICriOUrk.EC :1EAD rWv June 18 2002 4: 22pIIr 2 e T �, trti, 11lV U — r r•Y).4cgr JaYK ar;; •e0 a t4! Mx Galt x+: ,wcr rYf der ;:.. Cia1t•S• fYllq ; br Cr ^e Da" Y ,G t•+c o >`t . 1 Ole I7.^ sY - _ _ n wy OD•GOL oea+' W—W Y • X1�E 29 ND TOBACCO UST. CONTR9UIE TO THE DEATH' ap, ..IBS ONNCrAN Oa T1SSI;E- _ > -. ❑ YES ❑ NC U1WUK?YRN .E- J� erom E Janu,awicz, Hall County ,.1t EXHIBIT "A" tiq alr� A e? nr Hall Co A t t y I � <_i '.C' YES ❑ 4L: ;orney, 117 E 1st, Grand Island, NE _____ —3A DA-- FILED BY aE015tw,MP 4A; D1ar r JUL 1 20W