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I 87-401026 STATE OF NEBRASKA ) AFFIDAVIT OF DEATH OF ss. JOINT TENANT COUNTY OF PALL ) HAROLD O'BRIEN, being first duly sworn on his oath, de- poses and says that he resides at 210 West 11th Street, Wood n s..... -.. H '1 tram Nebraska; that his wifef Mar Mildred s. County, t nnr �' Hall, 7 n yam•• L° . that O'Brien, died May 21, x97005, Win= Ha�l county, ebrask.a: a copy of her death certificate is attached hereto as Exhibit "A "; that his wife left no property separately owned by her and that all property subject to consideration and computation '� -�- -. f --- -cvz c`-vvc is .-rit -nce Tax any PeApral _ l.iJi utLCYasu ;tu ti.J.v3i vL uity �f - ` '^`� Estate Tax was property owned by the decedent Vin joint tenancy with this Affiant, her surviving spouse; that the total value of all such property as of May 21, 1985, valued at its fair market value on that date, did not equal or approach the sum of $400,000.00; that Affiant is entitled to an exemption in computation of both Nebraska Inheritance Tax and Federal Estate Tax of the total value of all such taxable property received by him by reason of the death of the decedent or otherwise, and that there is no Nebraska Inheritance Tax nor Federal Estate Tax due or owing by this Affiant by reason of property passing to him upon the death cf Mary Mildred O'Brien on May 21, 19854 Real estated owned by the parties in joint tenancy is described as follows: The East Forty -five i15! Feet of Lot Eight (8) and the West Forty -two (42) Feet of Lot Nine (9), all in Block Seven (7), Original Town of Wood River, Hall County, Nebraska. �f� �. �J �i 01i 11 HAROLD O'BRIEN, Affiant SUBS ED and SWORN to before me a Notary Public this /9 day of : 1987. j7. NrIlry Public My commission expires: �! / F y, Z 9 fiiiiKllOfAlMfner�Prsm )