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due. 1. Name of Decedent: Date of Death: Domicile at Death: Name of Surviving Spouse: Date of Marriage: Return to: Jamie Mues Jankovitz °� P.O. Box 639 �, Grand , NE 68802 -0639 AFFIDAVIT OF MARITAL STATUS Comes Now, the undersigned, being first duly sworn upon oath, deposes and states that the undersigned knows the Decedent and the surviving spouse of the Decedent and that the following information is true and correct. Roberto Coronado Fonseca April 29 2017 Hall County, Nebraska Rosa M. Gomez de Coronado, aka Rosa Maria Gomez de Coronado, aka Rosa Maria Gomez Moreno, aka Rosa Gomez de Coronado, aka Rosa Maria Coronado June 6, 1973 2. The Affiant is the wife of the Decedent and in that capacity is familiar with the marital status and the death of the Decedent. 3. That there is no federal estate tax, Nebraska inheritance tax or Nebraska estate tax 4. Title to the following described real estate is held by the Decedent and the surviving spouse in joint tenancy, to wit: Parcel 1: The Easterly Twenty -three and Five Tenths feet (23.5') of Lot Twenty -three (23) and all of Lot Twenty -four (24) and the Westerly Three feet (3') of Lot Twenty -five (25), in Block Three (3) in Blain Addition to the City of Grand Island, Hall County, Nebraska. (Physical address: 556 E. 18` St., Grand Island, NE) AND Parcel 2: Lot Nine (9), Ross and Ashton Park, a subdivision of parts of Lots Fourteen (14) and Eighteen (18), of the County Subdivision of the West Half of the Southwest Quarter (WASW1 /4), and a part of the East Half of the Southwest Quarter (E' /2SW1 /4) of Section Fifteen (15), in Township Eleven (11) North, Range Nine (9), West of the 6' P.M., Hall County, Nebraska. (Physical address: 207 E. Ashton St., Grand Island, NE)