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Ni <br />_B <br />Cfl <br />M� <br />W <br />BI <br />{ <br />7 <br />rJ <br />) <br />n <br />W <br />Return to: Elizabeth Obermiller <br />4255 Michigan Ave. <br />Grand Island, NE 68803 <br />AFFIDAVIT OF MARITAL STATUS <br />STATE OF NEBRASKA ) <br />) ss. <br />COUNTY OF HALL ) <br />—i <br />` rn <br />0Q4 <br />COMES NOW, the undersigned, being first duly sworn upon oath, and deposes and states <br />that the undersigned knows the Decedent and the surviving spouse of the Decedent and that the <br />following information is true and correct. <br />1. Name of Decedent: James A. Obermiller <br />Date of Death: August 15, 2019 <br />Domicile at Death: Grand Island, Hall County, Nebraska <br />Name of Surviving Spouse: Elizabeth E. Obermiller <br />Date of Marriage: August 16, 1969 <br />2. The Affiant is the attorney for the Decedent's spouse and, in that capacity, is familiar <br />with the marital status and the death of the Decedent. <br />3. That there is no federal estate tax, Nebraska inheritance tax or Nebraska estate tax <br />due. <br />4. Title to the following described real estate is held by the Decedent and the surviving <br />spouse in joint tenancy, to -wit: <br />Lot Two (2), Block One (1), Capital Heights Fourth Subdivision, being a tract of <br />land comprising a part of the Southwest Quarter (SW1/4) of Section Two (2), <br />Township Eleven (11) North, Range Ten (10 West of the 6th P.M., in Hall County, <br />Nebraska. <br />5. As of the date of death, the real estate had a fair market value of $156,385. <br />6. The Decedent and the surviving spouse were married as of the date of death. There <br />is no Nebraska inheritance tax lien by reason of Nebraska Revised Statute §77-2003. <br />FURTHER Affiant saith not. <br />1 <br />-7112'{`�//> <br />Denise D. Myers <br />Subscribed and sworn to before me this 1 ^ day of December, 2019. <br />GENERAL NOTARY • State of Nebraska '(`(--; LFcE,-- <br />!' SUSAN R. MRKVICKA Nota Public <br />""'* My Comm. Exp. June 8, 2021 Notary <br />ENTERED AS INSTRUMENT NO <br />