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<br />WHENTBSOOPVCAMW DE RAISED SEAL OF THE NEBRASKA
<br />SnTW ITCERTFES THE BELOW TO BE A TRUE.COPYOF THE!
<br />THE NEBRASKA HEALTH AND HUMAN SERWCES SYSTEM, WTAI
<br />THE LEGAL DEPOSITORYFOR WTAL RECORDS
<br />DATE OF ISSUANCE
<br />DEC 10 2002 200211/162 ASSISTANFB
<br />LWCOLN, NEBRASKA HEALTH AND MAKAN'4
<br />STALE OF NEBRASKA- DFPARI OF Iff.AI.TD AND aE1NAN SEHV M I
<br />VITAL STATISTICS
<br />CFRTIFICATF (1F DFATH
<br />13991
<br />oFrmFxi -xnME RvSi -- 4xooLE i/.5*
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<br />December 5, 2002
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<br />WHENTBSOOPVCAMW DE RAISED SEAL OF THE NEBRASKA
<br />SnTW ITCERTFES THE BELOW TO BE A TRUE.COPYOF THE!
<br />THE NEBRASKA HEALTH AND HUMAN SERWCES SYSTEM, WTAI
<br />THE LEGAL DEPOSITORYFOR WTAL RECORDS
<br />DATE OF ISSUANCE
<br />DEC 10 2002 200211/162 ASSISTANFB
<br />LWCOLN, NEBRASKA HEALTH AND MAKAN'4
<br />STALE OF NEBRASKA- DFPARI OF Iff.AI.TD AND aE1NAN SEHV M I
<br />VITAL STATISTICS
<br />CFRTIFICATF (1F DFATH
<br />13991
<br />oFrmFxi -xnME RvSi -- 4xooLE i/.5*
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<br />]. ORE OP OEATX RAI INv ✓nn
<br />Raymond LeRo Ten
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<br />December 5, 2002
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<br />V "OEFI OPV aM,E OF BiOW Mmrt ay ✓eM
<br />MAN wr
<br />74
<br />"wRS Mw
<br />18, 1928__
<br />Howard County, Nebraska
<br />September _.
<br />- -_
<br />OF
<br />snnAl ascuenY NUMBED n.cF OE DEAxx
<br />1T ❑K ..I CITHEN ❑ x,ISM xm..
<br />507 -32 -8675 __
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<br />W CILITV N,Im Inrclnaulm,.gre wmnmrvmml EF CUgAen 1AIDEuu
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<br />St. Francis Medical Center
<br />& LITV. TOw "Ox ICLATONOF OEATM _ Iu.a Iv LAIT5 M CaxTY OF DEACON
<br />Grand Island .A ® "° ❑ Hall
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<br />p� EWnenlerya5e¢Mary lO.19 Cdryu 11 ew 51
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<br />CabinetmMaker Stoltenberz Cabinet CO. 12
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<br />F.IIER.v.ME ,wsT - MIDDLE us,
<br />MDrxER EiBS9 MIDDLE MAlDya wax,ME
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<br />Anna Johansen
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<br />I n, ,C,12 /6/1950
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<br />es n War 152 Irene C. Ten
<br />mwuM<xT MAIONGPODPE66 i9TVEETOxufu uO. uIVOP TOw «.Te.F IiPi
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<br />Dr. Gordon J. Hrnicek 729 North er G nd Islan Ne a a _
<br />-
<br />IxAR
<br />OREFII ..R Mm I TO
<br />DEC 9 2002
<br />
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