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STATE OF NEBRASKA ) ss: GENiRAL NOTARY - State of Nebraska JAMIE MUES JANKOVITZ My Comm. Exp. May 25, 2018 PREPARED BY: Jamie Mues Jankovitz, #20754 BRADLEY LAW OFFICE, PC 202 West Third Street P.O. Box 639 Grand Island, NE 68802 Telephone: (308) 382 -2128 jamie@bradleylawoffice.com Page 1 of 1 ary Public Return to: 9 Jamie Mues Jankovitz F P.O. Box 639 Grand Island, NE 68802 -0639 AFFIDAVIT OF MARITAL STATUS WITH DEATH CERTIFICATE 'r7 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. 1. Name of Decedent: Marion North Date of Death: January 20, 2018 Domicile at Death: Hall County, Nebraska Name of Surviving Spouse: Karen Kay North Date of Marriage: December 2, 1972 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 due. 4. Title to the following described real estate is held by the Decedent and the surviving spouse in joint tenancy, to wit: Lot 2, Block 3, Fairway Crossings at Indianhead Golf Club First Subdivision in the City of Grand Island, Hall County, Nebraska. (Physical address: 4227 Indianhead Rd., Grand Island, Nebraska) 5. As of the date of death, the real estate had a fair market value of $278,522.00. 6. The Decedent and the surviving spouse were married as of the date of death. There is no Nebraska inheritance tax lien by reason of Nebraska Revised Statute § 77- 2003. There is no Nebraska estate tax lien by reason of Nebraska Revised Statute §77- 2102. 7. Original Death Certificate of Marion North attached hereto. FURTHER THIS AFFIANT SAYETH NOT. 10 11 Karin Kay Nor' ' ffia COUNTY OF HALL SUBSCRIBED and sworn to before me on this day of 1e 6414,1,U'`L t . , 2018 by Karen Kay Nortlr,° °Affiant.