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CASH CHECK 4D REFUNDS: CASH N RECKK O Utw.0 e Iv HALL COUNTY NE oa INST 125 0 2 I 93 /015AP?28 AID I KRISTI WOLD REGISTER OF DEEDS RECORD AND RETURN TO: Kevin A. Brostrom, #16208 /1811 West 2nd St., Suite 360 Grand Island, NE 68803 (308) 382-7810 REVOCABLE TRANSER ON DEATH DEED NOTICE TO GRANTOR .aXi9 This form must be recorded with the Register of Deeds of the County in which the property is located before your death and it also must be recorded with the Register of Deeds of the County in which the property is located within 30 days after it was signed. If either of these requirements is not met, this form will not be effective. IDENTIFY INFORMATION ABOUT OWNER Grantor making this deed: Lola J. Ruzicka, a single person 4047 Buckingham Drive Grand Island, NE 68803 NOTICE TO REGISTER OF DEEDS This is a transfer on death deed and Form 521 is not required with the filing of this Transfer on Death Deed under Neb. Rev. Stat. §76-214(2)(b). LEGAL DESCRIPTION The following real estate is transferred by this document, effective at the death of the Grantor to the Primary Beneficiary or to the Alternate Beneficiary as provided below: Lot Forty -Nine (49), in Castle Estates Subdivision, Hall County, Nebraska PRIMARY BENEFICIARY Grantor designates the following Primary Beneficiaries of this revocable transfer on death deed: Michael J. Ruzicka 19646 E, 140 Street South, Broken Arrow, OK 74014 Ricky J. Ruzicka 5153 Skylab Avenue NE, Salem, OR 97305 Bradly A. Ruzicka 1316 Independence Ave., Grand Island, NE 68803, All as Tenants in Common TRANSFER ON DEATH At the Grantor's death, Grantor transfers Grantor's interest in the described property to the Primary Beneficiaries as designated above. The transfer occurs at the death of the Grantor.