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<br />FILE WITH THE NgBRASKA DEPARTMENT OF HEAtTH AND HUMAN SERV��'E9� l,7'�L�EE'O�f� C. I: .�-.::
<br />OFFIGE, WHICH IS THE LEGAL DEPOSIT�RY FOR VITAL RECORDS. � �' :,•' 5;• ��}
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<br />DATE OF ISSUANCE ` " ' �� i' � �
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<br />. Honnie Irene Kin Femaie 8-11-1996
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<br />Belleville KS 1� �� 65 ras. �°" s�. , 4-21-1931
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<br />Jahn A. Wagoner MD 8 N. A1 St. �rand Isiand
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