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69E0iZ0Z <br />1NST 20211 O t 3 b <br />CASH "ge <br />00 <br />CHECK <br />REFUNDS: <br />CASH <br />CHECK <br />RECORDED <br />HALL COUNTY NE <br />2D2q APR - I P 3: 58 <br />KRISTI I 'NOLO <br />REGISTER OF DEEDS <br />2.00 <br />REVOCABLE TRANSFER ON DEATH DEED <br />(SINGLE OWNER) <br />Notice to Owner <br />You should carefully read all information on this form. You May want to Consult a <br />Lawyer before Using this Form. <br />This form must be recorded with the Register of Deeds of the County in which the <br />property is located before your death and it also must be recorded with the Register of <br />Deeds of the County in which the property is located within 30 days after it was signed. <br />If either of those requirements are not met, this form will not be effective. <br />Identifying Information about Owner: <br />Name of Owner: <br />Clayton LeRoy Green <br />Mailing Address of Owner: <br />1023 W 1st Street, Grand Island, NE 68801 <br />Notice to Register of Deeds <br />This is a transfer on death deed and form 521 is not required with the filing of this <br />Transfer on Death deed under Neb. Rev. Stat. Section 76-214(2)(b). <br />Legal Description <br />The following real estate is transferred by this document, effective at the death of the <br />Owner to the Beneficiaries as provided below. <br />The Westerly Thirty Three (33) feet of Fractional Lot Four (4) in Block One Hundred <br />Twenty Two (122) of Koenig and Wiebe's Addition to Grand Island, and of Fractional <br />Block Six (6), of Arnold Place, In the City of Grand Island, Hall County, Nebraska. <br />Beneficiaries <br />I designate the following beneficiaries of a 100% share of the real estate covered by this <br />revocable transfer of death deed if the beneficiaries survive me. <br />Mackenzie L. Carstens, 503 Prairie Lake Boat Club # 38, North Platte, NE 69101 <br />