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<br /> ) SS.
<br /> = CnUtJ�'Y Q� HAI,z, I .
<br /> . = CdI�S N�W, the us�der�igrie�, befng �j.xa� $uly swarn upon oe.th. .-
<br /> dRpoee� ana etatee that the u:Ydexsign�d knowa the D�C�clent aend tha
<br /> euxv3,ving epouee aE the Decedsnt: 2xn� iMati the fallowi�n.g infarma�tion
<br /> __ - 3e true and co�rect.
<br /> --- 3., Narae oi Decedent�: Deuaine W�?'�i�m �isrler.
<br /> I�ate a� i�sath: July 12, �.994. �
<br /> DomiGi].E at Da�e of Death: Grand I�].and, Hall County,
<br /> _ Nebraska. . �
<br /> -------- Name of Surviviaig S�ouse: Je�n Ann F�'�.sh�r.
<br /> - Da�e af M��r.iage: 1May 26. 1952. �
<br /> -�.�:�.,� 2. The Affian� is �he spous� nP �h� I�a�c�d�nx and�. �.s� th�+� , ��_
<br /> � capacity, ie f�amiliar with tl�ie maxital staxue an�l the de�.�h .�f,��he
<br /> _ _-<;i `' r�;..� D�Ced�nt.
<br /> -��a",±Siii��c,��
<br />-- '_'���!�;�� - 3. That there is �no fode�ral estate tax, I�i�braaka �nh�ri�ance .
<br /> �YA�;',�::;;;.:�: ��.:.� tax or Nebraslca eoCat� tax.
<br /> -__:':�..a1 �yh�
<br />. -- �.=—y�t-<—
<br /> -�w.,;T:�r g. Title to the following described real es�aCe is held by
<br /> -�-��� tho Decedent and the 2�►f f iant in �oint tenancy, to-wit:
<br />-`�__���,y Lat Four (�L) , Park Gaxdene Fif�h Subdivieion to th� Ci�y of
<br /> �-'--;;:�z� , :�! Grana �eiand, ria3.I CU11il4Y� i�ca�.iwo^�°�
<br />=°=sT-s'nt`.'.�t•:
<br />" "�° ' { '� 'ti�� comm�nly }cnown as 1602 Stolley P�rk Circle, Graad ieland, Nebraeka
<br /> '�`�{'�� �"' 68801. -
<br /> _ - �,•
<br /> _TN�;"/�'�,N� ���5,
<br /> .�f
<br /> '�. �'�:.:��' S. Ks c�E the date of death, the real �state hae a £�ir
<br /> -'�''�J°�=�"���.���� market value of $125,On0.00.
<br />-r-.&S��,':'u�L�l��T�ei
<br /> �ti�f'...:..��_:li{��H...�.�_
<br /> �:::,:„�.-.'.�±:��-.�-..� 6. The Decedent and the Affiant were married as o� the ate
<br /> ;i,-;�;�<;;'�-,.,�,.� oF death. There is no Nebraeka inheritance tax lien by r�aeon �f
<br /> ��-�:"=:'�M;i�:;;r:. . Nebrask� Revi9ed Statute Section 77-2003. Thare is no Nebraeka
<br /> '-�-'�-�- L_�_ �state tax lien by reason of Nebraska Revised Statute Section 77-
<br /> •:��.��,� . . 2102 . •
<br /> - .,�,.uan• .
<br /> . • FURTHER P,f f iant eaith not.
<br /> - . , A
<br /> �:...
<br /> = - ean Ann Fisher
<br /> �. � Subacribed and sworn to before me this ,l_'� day of Augus�,
<br /> =4�" � 1994. /�
<br /> _�� �
<br /> �fAHMI NOiMI►,Sq11 N Ni6r�
<br /> r K�D.�� Notary Public
<br /> _� ��h►i�►ExFl�b►m. __.
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