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~~~ :lO Q ~ :::=:.~-< tR m en r-..", l1\ ~ c\ c: = 0' (f) bl n X <"~ n Z ~ ~ c::r-, o -i ~, t-- C:t> -1..1\ <::: X ~ C :::3 Z-4 N N ~~, ~. m ~ ~~ = ~1"11 t:) IS QW~' n (I) -C -<0 IS ~ t.;:; ~ ::r: t---" 0-" C) en ~. 0' en ""'z cn~ IS .." ~ ..... 0 r ,.. CJ :x:m ~f N m ::0 :t>CO (Jl m ::3 ,:.:0 -->. CJ r- )> C/l ........ (f) I-' :;><; l> -C ...........'''"''-''' 20060425 ~IDAVI'1' co (J'l (f) Z OF MARITAL STATUS 0- STATE OF NEBRASKA S8: COUNTY OF HALL /~),j-O COMES NOW the undersigned, being duly sworn, deposes and says that the undersigned is the surviving spouse of the Decedent and that the following information is true and correct: 1. Name of Decedent: Nancy E. Boltz Date of Death: April 19, 2006 Domicile at Date of Death: Grand Island, Hall County, Nebraska. Name of Surviving Spouse: Roy W. Boltz, Jr. Date of Marriage: December 20, 1952 2. The Affiant is related to the Decedent as follows: surviving spouse. 3. There is no federal estate tax, Nebraska inheritance tax or Nebraska estate tax due. 4. Title to the real estate, as set forth below, is held by the Decedent and the surviving spouse of the Decedent in joint tenancy: Lot Twelve (12), Block Four (4), Lambert's Second Addition to the City of Grand Island, Hall County, Nebraska. 5. As of the date of death, the real estate has a fair market value of: $59,624.00. 6. The Decedent and Affiant were married as of the date of death. There is no Nebraska inheritance tax lien by reason of Nebraska Revised Statutes Section 77-2003. There is no Nebraska estate tax lien by reason of Nebraska Revised Statutes Section 77-2102. Further Affiant saith not. ~:~~~ -tA II-day of May, SUBSCRIBED AND SWORN to before me this 2006. GENERAl NOTARY. SIata of Nebrnska MARY J. UVING$TON My COmm. Exp. June 5, 2007 NO~b~C'~~ PREPARED BY: Mary J. Livingston #16122 Attorney for Affiant The Yancey, 2nd & Locust P. O. Box 1563 Grand Island, NE 68802 (308) 381-7301