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Return to: Stacie A. Goding f <br />611 N. Diers Ave., Ste. 1 l lX <br />Grand Island, NE 68803 <br />STATE OF NEBRASKA ) <br />COUNTY OF HALL <br />) ss. <br />COMES NOW, the undersigned, being first duly sworn upon oath, and deposes and states that <br />the undersigned knows the Decedent and the surviving spouse of the Decedent and that the following <br />information is true and correct. <br />1. Name of Decedent: Anton Usasz <br />Date of Death: January 19, 2015 <br />Domicile at Death: Grand Island, Hall County, Nebraska <br />Name of Surviving Spouse: Ruby Usasz <br />Date of Marriage: October 12, 1953 <br />2. The Affiant is the attorney for the Decedent's spouse and children and, in that capacity, is <br />familiar with the marital status and the death of the Decedent. Affiant can verify that Anton Usasz and <br />Anthony Usasz are one and the same person. <br />3. That there is no federal estate tax or Nebraska estate tax due. Nebraska inheritance tax has <br />been fully paid in Hall County Court case number PR16 -13. <br />4. Title to the following described real estate is held by the Decedent and the surviving spouse in <br />joint tenancy, to -wit: <br />Lot Four (4), Block One (1), Capital Heights Subdivision, Grand Island, Hall County, <br />Nebraska. <br />5. As of the date of death, the real estate had a fair market value of $138,386.00 <br />6. The Decedent and the surviving spouse were married as of the date of death. There is no <br />Nebraska inheritance tax lien by reason of Nebraska Revised Statute §77 -2003. <br />FURTHER Affiant saith not. <br />Subscribed and sworn to before me this <br />GENERAL NOTARY - State of Nebraska <br />KELLIE G. HOFFART <br />My Comm. Exp. July 17, 2018 <br />m <br />m m3, <br />C el Y <br />11 Z <br />=no <br />1-11 2a el_ • <br />I. <br />AFFIDAVIT OF MARITAL STATUS & IDENTITY <br />St ie A. Goding <br />day of March, 2016. <br />1 /Ain I <br />Notary ublic• wr F r i <br />c <br />c .r <br />I... --4 <br />Cr <br />00 <br />