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79~ ~~ri~83 AFFIDAVIT
<br />STATE OF NEBRASKA ) In re: Northwest Quarter (V1d',) Section Seven (7), Township
<br />ss. Ten (10) North, Range Eleven (11), idest of the 6th
<br />COUNTY OF HALL ) P. M., Hall County, Nebraska.
<br />B. J. Cunningham, Jr., being first duly sworn on oath, deposes and states that he
<br />was well and personally acquainted with Forrest Id. filler, also knowT. as Forest ldayne
<br />Miller, spouse of Blanche M. Miller, and that the said Forrest Id. Miller died October,
<br />17, 1971, at Grand Island, Hall County, ?Nebraska, and that the following is a true and
<br />exact copy of the Certificate of Death for the said Forest Idayne A4iller, issued by the
<br />State of Nebraska-Department of Health, Bureau of Vital Statistics, Nwnber i1-11966:
<br />srw•rE o~ neewASOCn-®Er, f, i ~i::!vit` i : ~ : ,u.•rb
<br />~rE rr.~ StrEiMiw ~ 1966 ~'
<br />CEitTtlr IC:ATE OF DEATH M - ~} ~r< U .,.,, ~~,.,~
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<br />tN•ORMANi-NINE-REUtgNSMO afAIRY IOOf>fs3 ,a•wn as . • s. +o . Cm d M.•.. w•r, a,
<br />Senstor Jack I311er SON
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<br />THIS CERTIFIES THE ABOVE TO BE A TRI3E COPY OF AN ORIGINAL
<br />CERTIFICATE ON FILE WITH THE STATE DEPARTMENT OF HEALTH.
<br />BUP.EAL` OF VITAL STATISTICS, WHICH IS THE LEGAL DEPOSITORY
<br />FOR VITAL RECORDS.
<br />.c~.~.ac..._ ~.: ~-
<br />piRECTOR 4f YITAI STAT15TK5 AND ASSISTANT STATE REWSTRAR
<br />sti'OLN. NEBRASKA ~ December 30, 1971
<br />Further Affiant sayeth not.
<br />Subscribed to and sworn to before me this ~_ day o~June, 1979. /~
<br />~1AI,Ip~ly-saER~a~Eau ~ . ~:~~;r>>` I %~~='~~!~~''~'I`
<br />~IWEST.N ~--- Notary i~c
<br />Qwia J ,.
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