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<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARrMENT OF HEALTH AND HUMAN SERVICES, IT CERTIFIES
<br />THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE W1TH THE NEBRASKA DEPARTMENT OF HEALTH AND
<br />HUMAN SERVICES, V1TAL RECORDS OFFICE, WHICH IS THE LEGAL DEPOSIi'ORY FOR VITAL RECORDS. �
<br />DATE OF ISSUANCE ✓'���a��� �' �""'O'" -
<br />STANLEY S. COOPER
<br />�➢ ft � � � ��� ASSISTANT ST,4TE REGISTRAR
<br />gi�U�t U DEPARTMENT OF HEALTH RND
<br />LINCOLN, NEBRASKA HUMAN SERVICES
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<br />STATE OF NE6RASIfA- DEPANTMENTOF HEALTH AN� HUMAN SEAYICES FlNANCE
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