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0 <br />r. <br />sq. 103246 <br />STATE OF NEBRASKA AFFIDAVIT OF DEATH <br />SS. or <br />COUNTY OF HAT-1 JOINT TENANT <br />EMA CAROLINE FOGT,, also known as Jackie Fcqt, being first <br />duly sworn upon her oath, deposes and says that she resides at <br />316 South Plum, Grand island, Hall County,, Nebraska; that her <br />husband, THEODORE R. FOGT,, died June 10, 19890 at the age of _gL <br />years in Grand Island, Hall Coubty, Nebraska; that a copy of his <br />Certificate of Death is attached hereto as Exhibit "A"; that her <br />husband; ltft.. no property separitel► owned by him, and that all <br />properly, -subject to consideration and computation for <br />deternkin,altic'n of any Nebraska Inhiritance Tax and Federal Estate <br />Tax.was-property owned by the Decedent in joint tenancy with your <br />Affiant, his surviving spouse; that the total value of all such <br />property as of June 10, 1989, valued at its fair market value an <br />that'dite, did not equal or approach the sum of ;600,000; that <br />.Aifiant is entitled to an exemption in computation of either • Nebraska Inheritance tax and Federai'•Estate Tax of the total <br />=valurcr- Of- tail eucn to xwle- received: - joy nor - by -reasan of <br />the death of the-Decedent or otherwise, and that there is no <br />Nebraska Inheritance Tax nor Federal , Estate Tax due or owing by <br />this Afflant by reason of the propertt passing to her upon the <br />..death of Theodore R. Fogt on June 10, 1989. <br />Real estate owned by the parties in joint tenancy is <br />described as follows: <br />Lot Three (3), B16--k Six (6), Koehler Place, <br />an Addition to the City of Grand Island,.Hall• <br />County, Nebraska <br />EIM CAROLINE FOGT <br />SUBSCRIBED AND SWORN to.before'me, a Notary Public, this <br />-day of June, 1989. <br />Notary�,;.Publlc <br />