|
<br />r
<br />
<br />
<br />r
<br />
<br />-~la
<br />
<br />I 507-03-4254
<br />Of
<br />GraM IslaM
<br />..-..ce -...... -"
<br />I~Nebraska ,. Hal:
<br />
<br />I ' '.iJMfel-Butler-G.!~des 1123 W. 2nd. Crand Il!IlaH~.'i
<br />
<br />It 2'" ec mber 2, 984 "" --iUiJ1" ~~______: - -- I~~--
<br />HMo. ,'<I .....," . HOHOUHClOOUO ~.. ,
<br />r " ~tf _,11<0,,'" I .
<br />nit Dec. 4 1984~,. 6: '5 ') ~ '....1 HL...... Ud ·
<br />J~.. -.... -r -.-..... -."9.... _;--..;;0;:;;' -;;;;'--;JI6 j""... .;;...--;-..;;.,;;;.;;-~ - ~...- ----
<br />: ............ . ... . "- .& '^ i: .... ~ ....... .. eM ,........ .. III............
<br />,.........., rdlel \#IttJ ~ - - "^-1.J L :2... l~.... ,..J.....
<br />r -- - __ 01 CllI'Iwltt t_"';~~,",,-UCI"" Oi'c6liNn;.nOi>in'll,po .. ,,,of'
<br />I,. W'U J. Landis MD. 2444 Faidley, Grand bland, HE. . 68801 ' .......,.
<br />
<br />I~-;'k.' ..~'~."
<br />I r'=~.;. ,~2~~~i~~t;~~[,.'I.ti"'~~c'yC::.:::iV:~
<br />
<br />I .!=,......-....-'TT"T.=7:,~~0y'. \,;j":'. ~ 1..,..." ".~_~_{,--,:.,_:___,j_:J.<l'_~_'.:~,__~"-----,~,,,-, .~
<br />! -....--....---..... ~ ; ---... \J'.
<br />
<br />w" ----,.; , -----
<br />I _to,oUhC~IOI. : -"'3-y:-
<br />
<br />I ,:' . .., ..._......r~~~.:..ffs\I=t;.~T=......:..!==~~
<br />I ~-:.. - =. "".. ......,...... "'1::" ..".-"r'::'-"" "".~~h,.i h.k-::-.'::':_.]',!~
<br />
<br />I -- ~~.-::.. ~~r.;a_".......' '--fioc;;;6..l1!!, ------"..'-00..-..;;---.--..,...01.00;;..........-
<br />I ... - ~ ,- ------~--._--._.--".----,,--------~---
<br />
<br />
<br />!
<br />I
<br />
<br />~.,;.~-:-:;.~:-:-.:, 1
<br />
<br />~':'"
<br />
<br />'. ,. ,': -;~
<br />( t'r-'t- ...."t t (,(1..-) '..
<br />
<br />- /'~. .y~ r \.
<br />
<br />j '"L __'~
<br />
<br />J- Jut.
<br />
<br />'---1''' - n.
<br />Cj.., 1!14~
<br />
<br />J
<br />
<br />/
<br />
<br />).,'{~-'7 Ii-.' f>~-.L
<br />
<br />WHEN THIS copy CARRIES THE RAISED SEAL OF THE NEBRASKA STATE
<br />DEtARTMINT or HEALTH, IT CERTIFIES THE ABOVE TO BE A TRUE COpy
<br />OP AN ORIGINAL RECORD ON FILE WITH THE STATE DEPARTMENT OF HEALTH,
<br />8U~U or VITAL~STATISTICS, WHICH IS THE LEGAL DEPOSITORY FOR
<br />V.ITAJ., .RECORDS.
<br />
<br />~L~
<br />
<br />DIRECTOR, BUREAU OF VITAL STATISTICS
<br />
<br />15SI.Icd De.:. 10. 1'184
<br />LINCOLN, NEBRASKA
<br />
<br />u
<br />
<br />L
<br />
<br />L
<br />
<br />-1
<br />
<br />I
<br />
<br />L
<br />
<br />-1
<br />
|