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STATE OF NEBRASKA ,�� ��;�,�, 2 l3 tJ
<br />WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA DEPARTMEIN�F OF H. EA�i'�, AND �� �
<br />HUMAN SERVICES, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORX-�,fNAi` R�'CORD i0N �
<br />FILE WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERI ,/ICES,:='V�li �i'��f7�1��
<br />OFFICE, WHICH IS THE LEGAL DEPOSITORY FOR VITAL RECORDS. � 1 � .�' i 1,x J ° �� �'`
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<br />DATE OF ISSUANCE ' �y ''". C� ��
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