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1. Name of Decedent: Lavern H. Hansen Date of Death: August 11, 2001 Domicile at Date of Death: Grand Island, Hall County, Nebraska Name of Surviving Spouse: Lorraine K. Hansen Date of Marriage: November 8, 1943 2. The Affiant is related to the Decedent as follows: surviving spouse. 3. Title to the following described real estate is held by the Decedent and the surviving spouse of the Decedent in joint tenancy, to -wit: The West One -half of Lots 175 and 176 and the West three feet of East One -half of Lots 175 and 176 in West Lawn, an Addition to the City of Grand Island, Hall County, Nebraska. 4. As of date of death, the real estate has a fair market value as follows: 5. That this affidavit is given as evidence that pursuant to Neb. Rev. Stat. 77 -2003 (Reis. 1996) no inheritance tax lien arising due to the death of decedent can 1 !T Y' T V r p 200203684 o s DAVIT A 7F I OF MARITAL STATUS w STATE OF NEBRASKA ) SS. COUNTY OF SHERMAN ) COMES NOW, the undersigned, being duly sworn, deposes and says that she is the surviving spouse of the Decedent and that the following information is true and — correct: 1. Name of Decedent: Lavern H. Hansen Date of Death: August 11, 2001 Domicile at Date of Death: Grand Island, Hall County, Nebraska Name of Surviving Spouse: Lorraine K. Hansen Date of Marriage: November 8, 1943 2. The Affiant is related to the Decedent as follows: surviving spouse. 3. Title to the following described real estate is held by the Decedent and the surviving spouse of the Decedent in joint tenancy, to -wit: The West One -half of Lots 175 and 176 and the West three feet of East One -half of Lots 175 and 176 in West Lawn, an Addition to the City of Grand Island, Hall County, Nebraska. 4. As of date of death, the real estate has a fair market value as follows: 5. That this affidavit is given as evidence that pursuant to Neb. Rev. Stat. 77 -2003 (Reis. 1996) no inheritance tax lien arising due to the death of decedent can