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WHEN THIS COPY CARRIES THE FL ED SEAL OF THE NEBRASKA HEALTH AND HUTA SERVICES <br />SYSTEAR IT CERTFES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH <br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATIO WHICH IS <br />THE LEGAL DEPOSITORY FOR VITAL RECORDS - L- <br />DATE OF ISSUANCE .lip <br />ANLEY t-400PER <br />SE P 2 7 2004 2004097'61 <br />ETTE±(#,SNiAR <br />LINCOLN, NEBRASKA HEALTH A AVI A61 JW <br />FURNWC �TlOti � WZLTAltiH>tiAL77b Dom► <br />vttsl <br />�*" .�$ = _ <br />ae�e. � 0 <br />66 0707 <br />snag Ro CBIiiTII�TCAT� <br />- - -• -- <br />OF DEATH WATZ 1= NO....._ .............. .......... <br />I. PLAOt 4w 6"vw [ <br />c...........,:..., �t=. y . "�.�a...:..;..,.,,R.,...�.t.,a <br />CITT. OR LOCATION <br />t. LEMiTN OF STAY NI 10 <br />t. CITY. TOWM. OR LOCATION <br />L MANE OF (if me it bap". d*w) <br />t. STIKET ADDRESS <br />TITII ID <br />2707 Nssc L <br />27O7.iiast let <br />t. W TEf NO <br />t. IS RESIDENCE "SIDE CITY Llmtm s /. FARM Anjo NCEt vu <br />pal NO <br />Fiat AfJwli LaM - <br />_I <br />A. DATIE - Motu AY Y~ <br />EATH <br />( ar p",t) it um= O'Brien <br />6 4 i6 <br />ax <br />6 COLOR OR MACE <br />7. MANRN D ® MEYER MARRIED . DAVIE -or ""TN <br />!. ASE (IR VWS <br />W WOER 1 YEAR m <br />r.w Dtiw w«.. >tr�.. <br />who <br />-O9 <br />we eleA+tr► <br />S7 <br />otvoNCFO <br />12. amm or ums meww" <br />1%. U$t/AL OCtWATMt "W #/AW* <br />Mb. KINOOIt DUSK M 40R RIDIISTRY 11. SWIMPLAM (Staff or i►tiq em") <br />� watt y sar�ily 11�t. aon I/ trotiaA <br />Y <br />8 P it Cor1 1 Blvf s L� <br />use <br />fATN EWS NAME 1 . M0"Wit S NA`M" NAME ' <br />!{. `NAME Of SN <br />" NYAND ON MIFE <br />tab1S OCCEMPED [VIER Mt Y. i ANNED PORAW M. We" ltGURITI/ to. 17. ago <br />t fw. r. � wtiwaw► t// w. tsw nrt w MMa a/ MNMI <br />tt r /� *� <br />0 i* itg I � , P fttm ii o -. <br />M qrD[ N NtAT1E tsxw alter aa>< a11at par am JS► ?. Rod (t <br />FART L OEATN WAS CAUSED 9V- <br />flout!" CANS (t1 <br />IrMe► rH�titr�j.. DIA To (�) <br />I <br />aMtt tMUt t11. <br />puff N. Otlit TO ONAVw @W NOS 1106011070 VIE MWIN AL ONSS1Nt <br />PAO & K f_&MAU4 WAS TM A <br />CPNNN110M NRIM1 M Fm 1(4) <br />MGMAWY IN THE ►AST 7 &% W M <br />TOO mw <br />Tuo m0 <br />ACClw%T fWCIDE NONICM <br />M- ONCINK MW OMY OCCURRED. (Sofas Rativs y1y11.(N iM ANt 1► i1trl i yMrw !i.> <br />0 0 O <br />. TMIE Of • 11YNM. DMN. Iattr <br />m"v aw tl. <br />p. 111. <br />WWW" accum" <br />. FL,ACt OF NlJrlfT p. p iR M AIAtYt lANlu, <br />1 �• tErttt. t to <br />Ml CiTY,1b1MN. 00 LOCATION COUNTY <br />No" AT (3 NOT N11N t 0 <br />.Alta <br />N4R11 AT WORK <br />t(. ! ottt+waled tow Ntoawd frooN . to oval tart tow am" on <br />Doww toow -solwt wow ##a dot* haft,! often##; a" ft tfW "0111 AW *A0Wjbdj t. /roles tla 0&"Qn attlttr. <br />�BIMarM <br />AODIZ Q $ti ,Eoenig S.t a <br />lk. lOAWlMIEfY <br />Grand s�,aWN ebr. <br />8- lid -E6 <br />o+hft <br />a <br />w" t , 'am.. « ) <br />Igo <br />X 491 7k M <br />PL slows S"sIRMA <br />,�1(t 3s�lrt• <br />s <br />-f <br />