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STATE OF NEBRASKA
COUNTY OF ADAMS
IIII~~IIR~11119n1111~1111~1111
NUM ~it~ fro<I? ~ ~~~
RD. COMP X ,-1~1-/ ~. `. ~?
COMPARE .~._._
CADAS Y 7~T MIMI AO ~
a r.
ADAMS COUNTY, NE
FILED
INST. N0.2,t~ 5 U
Date ~ Time,.~;~~
~R~~~o' ~~~tmaQnJ
REGISTER OF DEEDS
AFFIDAVIT FOR TRANSFER
OF REAL PROPERTY WITHOUT PROBATE
UNDER NEBRASKA PROBATE CODE
ss.
The undersigned, upon being first duly sworn, does hereby depose and state:
1. The value of the interest in all real property located in Nebraska of ROSEANNA
PRITTS, Deceased, which would otherwise be subject to probate proceedings, does not
exceed $25,000.00. Said real estate is legally described as follows:
Lot One Hundred Thirty-three (133) in Railroad Addition to the City of
Hastings, Adams County, Nebraska, according to the recorded plat
thereof.
2. Thirty (30) days have elapsed since the death of the Decedent on September 23,
2007, as shown by the certified or authenticated copy of the Decedent's death certificate
attached hereto and incorporated herein by reference.
3. No application or petition for the appointment of a personal representative is
pending or has been granted in any jurisdiction.
~l. Affiants are entitled to the real property held in the sole name of Decedent pursuant
to Nebraska Probate Code Section 30-24,129. Affiants are entitled to the real property by
reason of the homestead allowance, exempt property allowance, or family allowance, by
intestate succession, or by devise under the will of the Decedent.
5. Affiants have made an investigation and has been unable to determine any
subsequent will.
6. No other person has a right to the interest of the Decedent in the described
property.
7. The value of the real estate of the Decedent is $ 23, 000.00 ,and the value of
the entire estate of the Decedent is $ 24, 537.00
8. Affiants do hereby affirm that all statements contained herein are true and material
and further acknowledge that any false statement may subject Affiants to penalties relating to
perjury under Section 28-915. ~~
f
By: ~ .
Peggy Prit , A ant
Address: 311 S. Lexington Ave.
Hastings, NE 68901
Phone: (402) 461-4047
SUBSCRIBED AND SWORN to before me on ~ V ~(1r c9y ,~ , 200
SELLER & PARKER
P.C., L.L.O.
LAW OFFICES
726 EAST SIDE BLVD.
P.O. BOX 1288
HASTINGS, NE 68902
(402)463-3125
GENERAL NOTARY -State of Nebraska
MARJEAN HARTMAN Otary
My Comm. Exp. March 5, 2010
:~
/0~3
24081509
Carrie Heeren, Affiant
Address: 601 S. Boston Ave.
Hastings, NE 68901
Phone: (402) ~'8'Sj ~ 597 ~'
SUBSCRIBED AND SWORN to before me on Q~b-t<-<~C~--~ ~ , 200$.
GENERAL NOTARY-State of Nebraska N taoN ry Public
KAREN S. MILLER
~- - My Comm, Exp. June 23, 2010
1
Kenneth Pritts, Jr., Affiant
Address: 1327 W. D Street
Hastings, NE 68901
Phone: (402) ~/ ~ 3 - O ~ ~ ~`
SUBSCRIBED AND SWORN to before me on ~ , 201.
GENERAL NOTARY -State of Nebraska
IIR MARJEAN HARTMAN Nota Pubic
~j n _ My Comm. Exp. March 5, 2D10 ry
By:
mes A. Pritts, Affi t
Address: 3075 Baltimore
Hastings, NE 68901
Phone: (402) 463-3012
SUBSCRIBED AND SWORN to before me on ~C'J.lc)-..~ ~~ , 20~.
SEiLER & PARKER
P.C., L.L.O.
LAW OFFICES
726 EAST SIDE BLVD.
P.O. BOX 1288
HASTINGS, NE 68902
(402)463-3125
GENERAL NOTARY - State of Nebrask Ota PUbI IC
MARJEAN HARTMAN ry
My Comm. Exp. March 5, 2010
Form No. 150
I:WrobaleW-RWRITTS ROSEANNAWrridevit (Small Eslale - ReeQ.doc
a X13
STATE OF NEBRASKA 2 ~ O g 15 O
WHEN THIS COPY CARRIES THE RAISED SEAL OF THE NEBRASKA HEALTH AND HUMAN SERVICES
SYSTEM, IT CERTIFIES THE BELOW TO BE A TRUE COPY OF THE ORIGINAL RECORD ON FILE WITH
THE NEBRASKA HEALTH AND HUMAN SERVICES SYSTEM, VITAL STATISTICS SECTION, WHICH 1S
THE LEGAL DEPOSITORY FOR VITAL RECORDS.
DA~JppTI~E OF ISSUANCE r!'4'f ( r.","V
tl~®N ~ ~ ~OOT ., TAIV~'EY.S. COQPER
ASSI$TAIV't~')EA1`E R~'6.,IS~TRAR
LINCOLN, NEBRASKA HEA~h% AND,7iUMAN'3~'FjVI.C~.S '
STATE OF NEBRASfCA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANG,E ~ SIJPPqq~~T~
CERTIFICATE OF DEATH =~' ,i4J '('` ~ d
1. DECEDENT'S-NAME (Flrsl, Middle, ~ Last, - Sulfix) 2 SEJU.~~ " ~ 3 DATEOFD~ATf~•(Md' Day,Yr.).
Roseanna Pritts ~ernale ;,., Septeynl,~r 23;.2007
4, CITY AND STATE OR TERRITORY, OR FOREIGN COUNTRY OF BIRTH 5a. AGE-Last Birthday Sb. UNDER 1 YEAR 5aU(JDEA 1 dAw`. ''~ ¢'SDATEOF$IRTH~~(MO., Day,Yc)
(Yrs.) MOS. DAYS HOUR§•, MINS~ } 3 -
t
Fairbury, Nebraska 66 October 17, 1940
7. SOCIAL SECURITY NUMBER 6a. PLACE OF DEATH
506-46-1796 HOSPITAL: ^ Inpatlenl OTHER:" ^ NursingHome/LTC ^HosplceFadlity
Bb. FACILITY-NAME (II not institution, give street and number) ^ ERIOUIpatlent ~ ®Decedenl's Home
500 South Chicago ^ bCN ^ Oher(Speciry}
gc. CITY OR TOWN OF DEATH (Include Zip Code) 6d. COUNTY OF DEATH
Hastings 68901 Adams
ga. RESIDENCE-STATE gb. COUNTY gc. CITY OR TOWN
Nebraska Adams Hastings
Bd.STREETANDNUMBER 9e. APT. NO 9t. ZIP CODE gg.INSIDECITYLIMITS
500 South Chicago 68901 ~ vES ^ No
t0a. MARITAL STATUS AT TIME OF DEATH ^ Mauled ^ Never Mauled 1Db, NAME OF SPOUSE (First, Mltldle, Last, Sullix) II wife, give maiden name.
^ Marned, but separated ®Widowed ^ Divorced ^ Unknown
Kenneth Pritts
11. FATHER'S-NAME (First, Middle, Last, Suflix) 12. MOTHER'S-NAME (First, Middle, Maitlen Surname)
Charles Haskin Rosalie Riche
13. EVER IN U.S.ARMED FORCE59 Glve dales of service ilyea. 14a.INFORMANT--NAME ~ 14b. RELATIONSHIP TO DECEDENT
(Yes, no, orunk.) No Peggy Pritts Dau hter
15. METHOD OF DISPOSITION 16a,EM MER-SIGNATURE 15b.LICENSENO. 15c.DATE (Mo.,Day,Yr.)
®Burlal ^ Donatlon ~ - / ~ ~ September 28, 2007
^Crematlon ^Entombment 16d.C ME Y,CREMAT OR OTHER LOCATION CITY/TOWN STATE
^Removal ^Other (Speedy)
Guide Rock Cememtery Guide Rock Nebraska
17a. FUNERAL HOME NAME AND MAILING ADDRESS (Street, CIty orTown, Stale) - 17b. Zip Code
Brand-Wilson Funeral Home, 505 N Bellevue, Hastings, Nebraska 68901
_ CAUSE OF DEATH (See instructions and examples)
16. PART I.Enter lhechain olevents-•dlseases, InJudes, or compllcaUons--that directly caused the death. DO NOT enter terminal events such as cardiac arrest, APPROXIMATE INTERVAL
I
respiratory arrest. orventrlcular flbnllalion without showing the etlology. W NOT ABBREVIATE. Enteronly one cause on a IIne.Add additional Ilnes If necessary. I
IMMEDIATECAUSE: I onse!tedesth
IMMEDIATE CAUSE(Fhel (a) Heart Attack I Immediate
tlkeaseorcandttbnresuUlrp DUE T0, OR AS A CONSEQUENCE OF: I ousel to death
h deaar)
I
Sequen[lelyllslcondltlons,tt ro) Physical exertion I
I Minutes
any, leading tothecausellsled
DUE TO, OR AS A CONSEQUENCE OF: I onset to death
on Ilse a.
Enter he UNDERLYING CAUSE I
(dlseeseorlnluryhelhllleted (c) I
I
the evenk resuhinghdeah)
-
DUETO.ORASAGONSEOUENCEOF: I onset to death
IASr
I
(tl) I
1 g. PART II `OTHER SIGNIFICANT CONDITIONS-COndillons contdbuUng to the death but not resulting In the underlying cause given m PART I. 1g. YlAS MEDICAL EXAMINER
OR CORONER CONTACTED'+
x,~YES ^ NO
20. IF FEMALE: 21a.MANNEROFDEATH 21b.IFTRANSPORTATIONINJURY 21c.WASANAUTOPSYPERFORMED7
Nol pregnantwllhlnpas[year ~ Natural ^ Homldde ^ Driver/Operator
^ Pregnant at time of dea[tr ^ Accidenl^ Pending Investlgalion
^Passenger
^ YES X~'I NO
^ Not pregnant, but pregnant wllhln 42 days of deah
^ Suidde ^ Could not be delertnined ^Pedesldan 21d. WERE AUTOPSY-FINDINGS AVAILABLE TO
^ Not pregnant, but pregnant 43 days 701 yearbelore death ^ Other (Spedfy)
COMPLETE CAUSE of DEATH4
^Unknownifpregnanlwilhinlhepaslyear ^ YES ^NO
22a. DATE OF INUURY (Mo., Day, Yr.) 22b, TIME OF INJURY
m 22c. PLACE OF INJURY-At home, larm, street, lactory, ollice bulltling, construction slle, etc. (Specify)
22d.INJURY AT WORK? 22e. DESCRIBE HOW INJURY OCCURRED
^ YES ^ NO
221. LOCATION Of-INJURY-STREETS NUMBER, APT. NO. CITYROWN STATE ZIP CODE
z 23a. DnTE OF DEATH (MO., Day, Yr.)
~ z > 24a. DATE SIGNED (MO., Day, Yr.) 24b.TIME OF DEATH
b'~ a ~`, ¢ Sept. 24, 2007 12:30 P m
~N
~~~ 23b.UATESIGNED(Mo.,Day.Yr.) - 23c.T1ME0FDEATH m=~ 24c.PRONOUNCEDDEAD(Mo.,Day,Yc) 24d.TIMEPRONOUNCEDDEAD
E a z
cp rTl n a `~~~ Sept. 23, 2007
o -- 2:05- --p m- -..-.
$ 23d.Tothebe
st of my knowledge, death occurred at the Ume, dale and place aC F-O
~ w z 24e. On he basis of exa atlon a Lori Igatlon, Ih my opinion death occurred at
F m":~ and due to the cause(s) slated. (Signature andTlUe) ~ - - a ~ p ~ ~ the Ume, date an ce an e e cause(s) slated. (Signatue and ?Ills)
a ~a°
-___ .
o S
25. DID TOBACCO USE CONTRIBUTE TO THE DEATH? 26a.HASORGANORTISSUEDONATIONBEENCONSIDERED~ 26b.WASCONSENTGRANTED?
^ YES ^ NO ~ PROBABLY ^ UNKNOWN ^ YES ~ NO Not Applicable 1126a is NO ^ YES U NO
27. NAME, TITLE AND ADDRESS OF CERTIFIER (PHYSICIAN,CORONER'S PHYSICIAN OR COUNTY ATTORNEY) (Type orPnnl)
Michael G. Gilmour Dep. Adams Co. Atty. P.O. Box 71 Hastings, NE 68902-0071
26a. REGISTRAR'S SIGNATURE f 26b. DATE FILED BY REGISTRAR (Mo., Day, Yr.)
~1 • OCT g 2007
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