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1786L0ZZ0Z <br />Return to: <br />Jamie Mues Jankovitz <br />202 W. 3rd St. <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 />nn <br />n cn <br />r; I <br />1. Name of Decedent: <br />Date of Death: <br />Domicile at Death: <br />Name of Surviving Spouse: <br />Date of Marriage: <br />Norine Sue Valasek <br />August 14, 2022 <br />8400 N. Equus St., Cairo, NE 68824 <br />Randy E. Valasek <br />January 5, 1985 <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 />The North Half of the North Half of the West Half of the Southeast <br />Quarter (N1/2N1/2W1hSE1/4) of Section One (1) in Township Twelve (12) <br />North Range Twelve (12) West of the 6th P.M., Hall County, Nebraska. <br />(Physical Address: 8400 N Equus St., Cairo, NE 68824) <br />5. As of the date of death, the real estate had an assessed value of $241,840.00. <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 />C(ZiebLe <br />Ra dy E. V lasek, Affiant <br />STATE OF NEBRASKA ) <br />) ss: <br />COUNTY OF HALL ) <br />SUBSCRIBED and sworn to before me on this May of /) icf t ' , 2022 by <br />Randy E. Valasek, Affiant. <br />GENERAL NOTARY. State of Nebraska <br />JAMIE MUES JANKOVITZ <br />My Comm. Exp. May 25, 2026 <br />PREPARED BY: <br />Jamie Mues Jankovitz, #20754 <br />BRADLEY LAW OFFICE, PC <br />202 West Third Street <br />Grand Island, NE 68801 <br />Telephone: (308) 382-2128 <br />jamie(d bradleylawo f ced.com <br />Page 1 of 1 <br />N ril <br />r vy <br />i J <br />CD <br />CO <br />rn <br />otary Public <br />