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<br />THE NEBRASKA HEALTH AND HUMAN SERWCES SYSTEM, WTAL STATISAICITOCITCM-WNICH IS
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<br />DATE OF ISSUANCE 2002096115
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<br />LINCOLN, NEBRASKA HEALTHANDHUWAA(.SERVB:ESSYMM
<br />STATF.OF NEBRASKA- OEPAK'IT4N1' OF mod, 711 AND HUMAa SERVASTI APE SUPPORT
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<br />Joseph William
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<br />I January 27 2000
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<br />AS wa aNAm Agnes Skupas S, �824NDSicil Avenue Ravenna NE am FAILING
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<br />N 4/Yl+vv - 910 ' ®a,.�o ❑N...OJanuary 31, 2000' MtiE Pleasant Cemetery
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<br />Rasmussen Mortuary -371 Grand
<br />Ave.,
<br />Ravenna, NE 68869
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<br />Be. reverse side.
<br />'I CRy i
<br />�Nro E A,
<br />❑ _❑ _-
<br />DATE OFDEATH 1% SE, ..L
<br />/27/00
<br />1 TIE DATE :ONFO M✓ o :, ,ME OF DEATH
<br />f1��TAS 2/2/00 N N9: A. w N
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<br />D DO T7 YET 6E 'UDNOO NMNOWN
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<br />]� NAME AND AC OF CERTIFIER vSILNNU CORONER CHY SDAN OR(
<br />Richard
<br />A. Hranac, M.D. 3219 C
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<br />L -Ave., P. 0. Box 550
<br />❑ YR Xj] .v
<br />nev. NE 68848 -0550
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