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<br />THIS CCWCARRES THE RAISED SEAL OF THE NEBR4SKA HEALTHAND HUMAN SERVICES
<br />SYSTEM ITCERTIFES TIE BELOW TO BE ATRHE COFYOFTHE ORIGINAL ECORD ONFILEWITH
<br />THE NEBRASM HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION WHwRis
<br />THELEGAL DEFOSITORYFOR WTALECORDS.
<br />DATE OF ISSUANCE
<br />AUG 8 2002 200208572 ASSLSTANTSTATE Y REGISTRAR
<br />LINCOLN, NEBRASKA HEAL TN AND HUMAN SERVICES SYSTEM'
<br />STATE OF NEBRASKM DEPABTIENr OF F ui AND numAN SERVICES FOMANCB AND 5_ T
<br />VnI STATLSTICS - - - _<> ` 07328
<br />CERTIFICATE OF DEATH - - -
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<br />Riverdale Nebraska RR Januzry 14, 1914
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<br />Grand Island �AN ^o® A. M1e EHall
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<br />aTUEP -NAME EmsT aDOw usT .m„ER YEAST moum MAN DEN IDENADO
<br />UE Herbert Gard Marian Gollah.T
<br />`No Hampton Disbrow
<br />DAY NroPM.NT - u- ,iluo,DDR €v -. s BEE. oPPrD NO OTIORTOINAT srArs n >i -.
<br />1511 N. Ruston Ave., Grand Island, NE. 68803
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<br />1123 West Second, Grand Island, NET 68801
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<br />NAME DDDTS..�T I ANTJIJA =OU,NDRIDEN1ATTORNEY
<br />Gordon J. Hrnicek MID 729 N. Custer, Grand Island, NE. 68803
<br />sa a_.T, +AR -- DATE A. rwe.b„ nT -
<br />JUL 1 0 2002
<br />West Lawn Lot 177, in theZi y of Grand Island, Hall County, Nebraska
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