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<br />STATE OF NEBRASKA )
<br />) ss:
<br />COUNTY OF HALL )
<br />C>zt/),�T �1_o4- X33
<br />Ernest Kozisek, being first duly sworn upon oath, deposes and
<br />states as follows:
<br />1. That the undersigned Affiant is of legal age, a resident
<br />of Grand Island, Hall County, Nebraska.
<br />2. The undersigned Affiant and Dolores May Kozisek, Husband
<br />and Wife, were the owners of the following described real estate:
<br />Lot Seventeen (17), Block D, Park -View Subdivision to the
<br />City of Grand Island, Hall County, Nebraska.
<br />as Husband and Wife in Joint Tenancy.
<br />3. That on the 7th day of June, 2002, Dolores May Kozisek,
<br />the spouse of the undersigned Affiant, died. Attached hereto
<br />appears a certified copy of the Death Certificate of Dolores May
<br />Kozisek.
<br />4. At the time of her death, Dolores May Kozisek was married
<br />to the undersigned Affiant.
<br />5. By virtue of the death of Dolores May Kozisek, the
<br />undersigned Affiant became the sole owner of the above - described
<br />real estate, and by virtue of Section 77 -2004, R.R.S. Nebraska, the
<br />interest in the above - described real estate passing to the
<br />undersigned Affiant, Ernest Kozisek, as surviving Joint Tenant, is
<br />not subject to Nebraska Inheritance Tax.
<br />FURTHER AFFIANTT SAITH NOT.
<br />Dated the a5�day of June, 2002.
<br />NOW ON this c S�bday of , 2002, personally appeared
<br />before me, the undersigned Nota Public in and for the County of Hall and State
<br />of Nebraska, Ernest Kozisek, to me known to be the identical person who executed
<br />the foregoing Affidavit, and acknowledged the execution thereof to be his
<br />voluntary act and deed.
<br />IN WITNESS WHEREOF, I have hereunto affixed my hand and seal the day and
<br />year first above written.
<br />Notary Public
<br />GENERAL NOTARY -State of Nebraska
<br />'�' VICKI L, GEWECKE
<br />My Comm, E %D. Jan. 24, 2005
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<br />C>zt/),�T �1_o4- X33
<br />Ernest Kozisek, being first duly sworn upon oath, deposes and
<br />states as follows:
<br />1. That the undersigned Affiant is of legal age, a resident
<br />of Grand Island, Hall County, Nebraska.
<br />2. The undersigned Affiant and Dolores May Kozisek, Husband
<br />and Wife, were the owners of the following described real estate:
<br />Lot Seventeen (17), Block D, Park -View Subdivision to the
<br />City of Grand Island, Hall County, Nebraska.
<br />as Husband and Wife in Joint Tenancy.
<br />3. That on the 7th day of June, 2002, Dolores May Kozisek,
<br />the spouse of the undersigned Affiant, died. Attached hereto
<br />appears a certified copy of the Death Certificate of Dolores May
<br />Kozisek.
<br />4. At the time of her death, Dolores May Kozisek was married
<br />to the undersigned Affiant.
<br />5. By virtue of the death of Dolores May Kozisek, the
<br />undersigned Affiant became the sole owner of the above - described
<br />real estate, and by virtue of Section 77 -2004, R.R.S. Nebraska, the
<br />interest in the above - described real estate passing to the
<br />undersigned Affiant, Ernest Kozisek, as surviving Joint Tenant, is
<br />not subject to Nebraska Inheritance Tax.
<br />FURTHER AFFIANTT SAITH NOT.
<br />Dated the a5�day of June, 2002.
<br />NOW ON this c S�bday of , 2002, personally appeared
<br />before me, the undersigned Nota Public in and for the County of Hall and State
<br />of Nebraska, Ernest Kozisek, to me known to be the identical person who executed
<br />the foregoing Affidavit, and acknowledged the execution thereof to be his
<br />voluntary act and deed.
<br />IN WITNESS WHEREOF, I have hereunto affixed my hand and seal the day and
<br />year first above written.
<br />Notary Public
<br />GENERAL NOTARY -State of Nebraska
<br />'�' VICKI L, GEWECKE
<br />My Comm, E %D. Jan. 24, 2005
<br />
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