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WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
<br />SYSTEM, IT CERTIFIES THE BELOW TO SEA TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
<br />THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH IS
<br />THE LEGAL DEPOSITORY FOR VITAL RECORDS. - -
<br />XfDATE O I�s
<br />AU G 1F O W ANLEY 9. COOPER
<br />ASSISTANT STATE REGISTRAR
<br />LINCOLN, NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM
<br />200203808
<br />STATE OF W --WAS" — D"ARTMENT OF HEALTH
<br />MJREAV OF MAL STATmT10a 95-12124
<br />CERTIFICATE OF DEATH
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<br />Howard John. Chiu�bos
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