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<br />STATE OF NEBRASKA , tv~T
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA pEPARTMEN~~ ND
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF rHE.~e~~Yt~p~v
<br />F7LE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVI~'E~ry AE- FA ~
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. ~~ `~~ •' ~'"`,~- ~ ~ :~ ~r ~ ~~~
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<br />DATE OF ISSUANCE ;~fy
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<br />AuG o 2 ~o~0 201045779 ~ "~T ~~;
<br />,O°P~ARTMENT't~;` H,EALT1d .~i~Vl3'
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<br />ENRER ONLY ONE CAVSE PER LRE FOR iai SDI. ANO Icq
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<br />77A DATE OF DEJ17N Ab.. J _-".-.--»..-._
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<br />Y LOCA71[irY GTY AR TGN1 RATE
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<br />Itad ~ PARj M N= FEIIW.E. WAS T11Eiif A 74 AUTDP$y
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<br />Dr. Kirt~rly A. Nickels '729 N. Custer Grand Island.. Nebraaek~N r,~tnn~
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