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86i90ZZ@Z <br />:i,1 <br />CO <br />I <br />Return to: Michael P. Kneale <br />2615 Riverview Dr. <br />Grand Island, NE 68801 <br />AFFIDAVIT OF MARITAL STATUS WITH DEATH CERTIFICATE <br />Comes Now, the undersigned, being first duly sworn upon oath, deposes and states that <br />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: Melvin Dean Sems <br />Date of Death: June 17, 2022 <br />Domicile at Death: Grand Island, Hall County, Nebraska <br />Name of Surviving Spouse: Marlys D. Sems <br />Date of Marriage: January 19, 1964 <br />1(0.0c- <br />2. The Affiant is the spouse of the Decedent and in that capacity is familiar with <br />the marital 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 />Legal Description: <br />LOT THREE (3), BLOCK TWO (2), COLONIAL ESTATES <br />TENTH SUBDIVSION, HALL COUNTY, NEBRASKA <br />(Physical Address: 3111 Memphis Place, Grand Island, NE 68803) <br />5. As of the date of death, the real estate had an assessed value of $246,136.00. <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 <br />Statute § 77-2003. There is no Nebraska estate tax lien by reason of Nebraska <br />Revised Statute §77-2102. <br />FURTHER THIS AFFIANT SAYETH NOT. <br />STATE OF NEBRASKA <br />COUNTY OF HALL )) <br />ss: <br />TrialltirAffian' t <br />SUBSCRIBED and sworn to before me on thisaday of aG(.Q U/9"" , 2022 by <br />Inadif 0. Sem , Affiant. <br />PREPARED BY: <br />Michael P. Kneale #19324 <br />Telephone: (308) 379-1073 <br />2615 Riverview Dr. <br />Grand Island, NE 68801 <br />Mike.kneale@charter.net <br />Notary Pub <br />Page 1 of 1 <br />fY�t�a�ca�.v <br />