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� <br />� <br />� <br />� <br />0 = <br />N "'��' <br />- <br />W = <br />� <br />� <br />- <br />- <br />�� <br />� <br />� <br />C <br />wAi71 <br />�c ,T. <br />�- . , <br />_. c� cn <br />.'" co -� <br />1l 1 D� '� z- N <br />� � r ;'� " ' � -� rn O <br />� �� � o <br />L' r.� c� -n E_' <br />�, ,_�� -,� _` <br />r�� ' - . ��J <br />� _ _ rn � <br />- ; . _ � 9 --'m _ a c� � <br />�- - � <br />�J .. . I � � v f � � <br />(,� J � � <br />� �`y r `i � � � � <br />'�� _ L: tl ; F-� <br />- � 'n <br />j <br />� <br />� �epazed by and return to: Daniel D. Dvkstra P.O. Box 3086. Sioux City, IA 51102 L2) 255-8838 <br />AFFIDAVIT OF SURVIVING SPOUSE <br />State of Nebraska, �'l 2(�' County, ss: <br />I, the undersigned, Marvel M. Forgey, being first duly sworn upon oath, depose and state <br />as follows: <br />1. That I am the surviving spouse of Wayne R. Forgey, who died on June 14, 2009, a <br />resident of Springview, Keya Paha County, Nebraska; that a certified copy of said Decedent's <br />death certificate is attached hereto as Ea�hibit "A" and made a part hereof. <br />2. That on the date of death of said Wayne R. Forgey, he and the undersigned, as <br />husband and wife, owned as joint tenants with right of survivorship, and not as tenants in <br />common, the real estate described hereinbelow, to-wit: <br />Lot One (1), Meadow Lane Fourth Subdivision, Hall County, Nebraska. <br />3. That pursuant to Section 77-2004, R.R.S., 1943, effective January 1, 1983, the <br />above-described real estate is not subject to inheritance tax as all interests in said property passed <br />� 3/ <br />� <br />to the undersigned as the surviving spouse and joint tenant upon the death of Wayne R. Forgey. <br />