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0 <br />CASH <br />CHECK I (A 'Uig <br />REFUNDS: <br />CASH <br />n,CHECK <br />Iv <br />0= HAL' ' ; ? <br />es <br />N� <br />� <br />- 1ST 2023 0 0 2 4 1 2023 QIP e 3 <br />:0 <br />Return to: Jamie Mues Jankovitz 4YVi <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 the <br />undersigned knows the Decedent and the surviving spouse of the Decedent and that the following <br />information is true and correct. <br />1. <br />Name of Decedent: Edward C. Berst <br />Date of Death: September 11, 1998 <br />Domicile at Death: Hall County, Nebraska <br />Name of Surviving Spouse: Charlotte A. Berst <br />Date of Marriage: September 25, 1955 <br />2. The Affiant is the wife of the Decedent 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 tax 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 One (1), in Block Five (5), in South Grand Island, an Addition <br />to the City of Grand Island, Hall County, Nebraska. <br />5. As of the date of death, the real estate had an assessed value of: $90,600.00 <br />6. The Decedent and the surviving spouse were married as of the date of death. There is <br />no Nebraska inheritance tax lien by reason of Nebraska Revised Statute § 77-2003. <br />There is no Nebraska estate tax lien by reason of Nebraska Revised Statute §77-2102. <br />FURTHER THIS AFFIANT SAYETH NOT. <br />Charlotte A. Berst, Affiant <br />STATE OF NEBRASKA ) <br />ss: <br />COUNTY OF HALL ) <br />SUBSCRIBED and sworn to before me on this 16 , day of , 2022 by <br />Charlotte A. Berst, Affiant. <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 />iamie(abradleylawofce. com <br />GENERAL NOTARY - State of Nebraska <br />JAMIE MUES JANKOVITZ <br />My Comm. Exp. May 25, 2026 <br />Pagel of2 <br />