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A 7 F I D A V I T <br />SUIR OF MENU►A <br />COUNTr or RAU <br />86-106110 <br />after being first duly sworn on oath deposes <br />and says that he is a resident of Grand Island, Hall County, Nebraska and that <br />he is licensed embalmer and funeral director in and by the State of Nebraska; <br />That, resident of <br />did die at on and that he did <br />prepare the body of <br />for burial on that date; <br />That, he did supervise the burial of the body of <br />in cemetery, located in <br />on <br />That, he did see the dead body of nd <br />did positively identify same; <br />Further affiant sayeth not. <br />Signed at Grand Island, Nebraska this day of <br />Affiant <br />Sub scribed and sworn to before me, a notary public, this // t4 day of t)e1m,4e-- <br />19-&. <br />:511 <br />Notary PMI�kic <br />My c onio ission expires er -�,2 -tog - - <br />L <br />