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<br />Certificate of Conveyance other than Deads of Real Estote j 1 <br />~~-~QU~Ti~3~ This Statemens is Confidential and Available <br />to Taxing Officials Only <br />This form pursuant to Section 76-?1-I R.R.S., 19-?±, as amended by thz 7th Szssion t=f the \ebra+l:u <br />Legislature, must bz completed ?nd attached to e4~ery mortgage or other wnteyaacz of real zstata `~ <br />e.cept deeds of real estate before such instrument is Ciled for recording. <br />~? <br />haIheS tr, Instrument ...._..-.... :: _,_... _,.~ , <br />T4'pe oC Instrument :.........::.'.`._..r-..:_....._..L_..._.... llatz ...-.--..-._... r3ook............ ! agz _.......... <br />i <br />Constderatton pstd Car Real £state ........................ s .:',t: ~::•4?•<....... '; <br />I `.) <br />Certification ;j <br />,1 <br />C ~ 1. tfte ttrstiersign~d, ha4iny INrtinnal I:noalz~ige ~,f thin transacriitn, zzrtiEj [hat the i~~rzgoing i; true <br />', Mnd.c+rtect. Sigoatarz_ ......_ ...__ .... ` .. ................ <br />I <br /> <br />J <br />I <br />