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� n n <br /> �" rn CDn <br /> �� z .. <br /> n (� � = c� � � <br /> � f) 2 � � � � b <br /> � � � c � � C.� ''-1 <br /> �• � � ., z -< �, C� .o <br /> � , ��,� w � -� � ;.� <br /> �i � �" o l�; O �3 �: ~ r= <br /> y <br /> �- Q M ...y �p p. �� o =n <br /> ' Q � � 3O �,j � <br /> t <br /> � C , � Gn � �� � 'L''�.+ <br /> � � � �� � <br /> cD <br /> � 99 10�55� �' �' ° � <br /> z <br /> 0 <br /> AFFIDAVIT OF MARITAL STATUS <br /> STATE OF NEBR.ASKA ) <br /> ) ss . . ��S <br /> COUNTY OF HALL ) a <br /> COMES NOW, the undersigned, being duly sworn, deposes and states <br /> that the undersigned is the surviving spouse of the Decedent, and that <br /> the following information is true and correct : <br /> l . Name of Decedent: Elmira Marie Pedersen <br /> Date of Death: April 17, 1999 <br /> Domicile at Date of Death: Grand Island, Hall County, <br /> Nebraska <br /> Date of Marriage: September 1, 1956 <br /> 2 . The Affiant is the Decedent' s surviving spouse. <br /> 3 . There is no Federal Estate Tax, Nebraska Inheritance Tax or <br /> Nebraska Estate Tax that arose, or can arise, by virtue of the <br /> Decedent' s death. <br /> 4 . Title to the followinq described real estate was held by the <br /> Decedent and Orville H. I�edersen, the D�cedent' s spouse, on the date <br /> of the Decedent' s death, to-wit: <br /> Lot Five (5) , Fairacres Subdivision, Grand Island, Hall <br /> County, Nebraska. <br /> 5 . As of the date of death, the real estate has a fair market <br /> value of $71, 188 . 00 . <br /> 6. The Decedent and Orville H. Pedersen were married as of the <br /> date of death of Elmira Marie Pedersen. There is no Nebraska <br /> Inheritance Tax lien, and no Nebraska inheritance tax lien. <br /> AND FURTHER AFFIANT SAITH NOT. <br /> Orvi le H. Pede en <br /> Subscribed and sworn to before me this � � day of June, 1999. <br /> flf GENERAL NOTARY-State ot Nebraska <br /> GALEN E.STEHLIK a 1 y PU 1 C <br /> My Comm.Exp.May t,2002 <br /> ESTATES\PEDERSEN.AFF <br />