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10 n (') p )..J"[' m % )>- ." m (n : ~~ c n :x: Z ....... () ?Ii; c:::> C) (f'J I nO' ~ J: ~ c;;r.t O-i 0 rn >~ ::3 c: )> N n en ~ ~' :;z-l I\.) en 'E'_ ~ :J: <:::) =:p -1m S r'Tl . -c 0 S ~~ (;) - -<0 0) V\ 0<":: W o "'T1 <::) ;: S ~ J(' Q """TJ 0 ""'z ~ r en CO 0 :x: rn f I\.) m \j )> co C) W C ::p r'Tl =:3 r- ::0 0 I)> ...r:: ~J~J (J) if> -t! ;:><; CO J> N 0 -- N C/) c..J .... en ~ p V' STATE OF NEBRASKA ) )S AFFIDA VIT OF DEATH OF COUNTY OF HALL ) JOINT TENANT Katherine A. Douglas, being first duly sworn on her oath, deposes and says that she resides at 2803 Kingston Circle, Grand Island, Hall County, Nebraska; that her husband, Dewayne T. Douglas, died April14, 2006 in Grand Island, Hall County, Nebraska; that a certified Death Certificate is attached hereto as Exhibit "A"; that her husband left no property separately owned by him and that all property subject to consideration and, computation for determination of any Nebraska Inheritance Tax and Federal Estate Tax as well as Nebraska Estate Tax was property owned by the Decedent in joint tenancy with your Affiant, his surviving spouse; that the total value of all such property, as of April 14, 2006, valued at its fair market value on that date did not equal or approach $2,000,000.00; that Affiant is entitled to an exemption in computation of either Nebraska Inheritance Tax, Federal Estate Tax and Nebraska Estate Tax by reason of the death of the Decedent or otherwise and that there is no such taxes due or owing by this Affiant by reason of property passing to her upon the death of De wayne T. Douglas. Real Estate owned by the parties in joint tenancy is described as follows: Lot Six (6) Imperial Village Fifth Subdivision in the City of Grand Island, Hall County, Nebraska. ,1Ia~c &-;lJ Katherine A. Douglas SUBSCRIBED and sworn to before me a notary public this Jo day of 1I1:=c~ 2006 6EHEAA1. NOTARY. State of Nebraska Lf2. ~ OUANE A. BURNS .. .L ~ ~ .' -<-..--, Comm. .Mareh22008 Notary Public