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c <br />C;) <br />Return to: Denise Myers <br />P.O. Box 505 <br />Cairo, NE 68824 <br />AFFIDAVIT OF MARITAL STATUS <br />STATE OF NEBRASKA ) <br />) ss. <br />COUNTY OF HALL ) <br />COMES NOW, the undersigned, being first duly sworn upon oath, and deposes and <br />states that the undersigned knows the Decedent and the surviving spouse of the Decedent <br />and that the following information is true and correct. <br />1. Name of Decedent: Kathleen Cleveland, also known as Lucille Kathleen <br />Cleveland <br />Date of Death: October 21, 2017 <br />Domicile at Death: Grand Island, Hall County, Nebraska <br />Name of Surviving Spouse: Charles R. Cleveland <br />Date of Marriage: October 12, 1951 <br />2. The Affiant is Decedent's son, and, in that capacity, is familiar with the marital <br />status and the death of the Decedent. <br />3. That there is no federal estate tax, Nebraska inheritance tax or Nebraska estate <br />tax due. <br />4. Title to the following described real estate is held by the Decedent and the <br />surviving spouse in joint tenancy, to -wit: <br />The Easterly Thirteen (13) Feet of Lot Eight (8), and the Westerly Thirty Nine <br />(39) Feet of Lot Nine (9), Block Six (6), Charles Wasmer's Addition to the <br />City of Grand Island, Hall County, Nebraska. <br />5. As of the date of death, the real estate had a fair market value of $125,261. <br />6. The Decedent and the surviving spouse were married as of the date of death. <br />There is no Nebraska inheritance tax lien by reason of Nebraska Revised Statute §77- <br />2003. <br />FURTHER Affiant saith not. <br />Loren D. Cleveland <br />Subscribed and sworn to before me this qday of December, 2017. <br />jisGENERAL NOTARY • Stale of Nebraska <br />DENISE D. MYERS <br />My Comm. Exp. Nov. 20, 2018 <br />Notary Public <br />