B105 L7 G1-2-10-11-12�
1.2 Huffman and Felton &Walt, Walton, Ne. 68461
QUITCLAIM DEED
JOHN A. FORSBERG and RUBY M. FORSBERG,
husband and wife
Grantor, whether one or more,
i
inconsideration of Two Hundred Fifty Dollars ($250.00)
receipt of which is hereby acknowledged, quitclaims and
conveys to BLAIR CEMETERY ASSOCIATION Grantee,
the following described real estate (as defined in Neb. Ree Stat. 0 76-201) in
Washington County, Nebraska:
Fraction One, Two, Ten, Eleven, and Twelve (1, 2, 10,
11 & 12), Lot Seven (7), Block One Hundred Five
(105), Blair Cemetery, Washington County, Nebraska.
i
I
Exe uted: ..........
- lz .......... ..... 4. /�.1, ........................
J,HN A. FOR RG RUB M. FORSBERG
i................................................
.............................. I..............................
..........................................................................................................................
.............................................................
State of .... NEBRASKA, ,,
ROY I: ANDERSON
ASHINGTON GENERAL NOTARY • State of N@A4
County of ..�...................... A
The foregoing instrument was acknowledged before me on .....OY......1...., 1990...............
by ,,,,John A.,,Forsberg and Ruby M: Fprs husba and wife.
....................� }
STATE OF NEBRASKA NOT RY HEW
County of.................................
Filed for record and entered in Numerical Index on..............................................
at ..... o'clock .....M., and recorded in Deed Record ............. I........... Page ..................
......... .............................
By:.. .......................
County or Deputy County Clerk
Register of Deeds or Deputy Register of Deeds
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TO BE FILE
Real Estate
Transfer: Statement
23 Deed Page
FORM
WITH REGIS
This Statement is Confidential—
for Tax Officials Only
Section
JL
OF DEEDS
• Read instructions on reverse side`:
Parcel Number
LVG
• THE DEED WILL NOT BE RECORDED UNLESS'THIS.STATEMENT IS SIGNED AND LINES 1 THROUGH 19 ARE PROPERLY COMPLETED •
COUNTY ASSESSOR'S USE ONLY
No, of Acres
County Name
County No.
Sales No..
Location I.D.
Property Type
(1) ❑ Single Family (4) ❑ Commercial (7) ❑ Agricultural (Total
Quality
No. of Stories
Story Height
No. of Acres
)
Multi Family () Industrial . (9) Mineral Interests ❑ ❑ ❑ ter
(2)5
, - .
Basement
1 Date of Sale ','
2 Date of Deed
(3) ❑ Home Sites (6) ❑ Recreational (9) ❑ Other
Cabins etc. -
Month Da Year
Y
Month 5— Da Year (� (�
Y �+L
3 Grantor's Name, Address, and Telephone
Year Built
4 Grantee's Name, Address,
and Telephone
Grantor's Name (Seller)
Grantee's Name.(Buyer)
Miscellaneous
John A. Forsberg and Ruby` M. Frsberg
Blair Cemetery Association
Street or Other Mailing Address
Miscellaneous
Street or Other, Mailing Address
Does land adjoin current operating
unit?
El YES ❑ NO
351 North Meridian S
Total Acres/Lots
26 Platted Lots
Zoning
City State Zip
e Junction, AZ 85220
Code
CityState
.,., NE
Zi Code
69008
Te ephone Number
982-0886
$ 00
Telephone Number
(402),,426-5244
Street Improvement
e era Employer Identification or Social Security Number
30 Improvement value
6 Type of Deed
of Grantee(s) (if more than two, attach list)
27Should this sale be used in an assessment/sales If no, give nonuseable sales code
ratio study? ❑ YES ❑ NO
u 1 t C 1 a lm Deed
7 Type of Transfer
X1 Sale ❑ Gift ❑ Exchange ❑ Foreclosure ❑ Satisfaction of Contract ❑ Other (explain)
8 Ownership Transferred in Full (if no, explain) 9 Was sale between relatives? (if yes, -state relationship)
® YES ❑ NO ❑ YES N NO
10 If the real estate was transferred for nominal 11 Was mortgage assumed? (if yes, state amount and interest rate)
consideration, what is the current market value? $ ❑ YES N NO $ %
12 Does this conveyance divide a current 13 Was sale through a real estate agent? 14 Was real estate purchased for same use? (if no, explain)
parcel of land? ❑ YES XI NO El YES N NO YeS
15 Address of Property. City State Zip Code
B1,91-t-GeMetery Blair 4., NE 68008
16 Legal Description
Fraction 1, 2, 10, 11 & 12, Lot 7, Block 105, Blair Cemetery, Washington County,
Nebraska:
17 Total purchase price including any liabilities assumed.. loo
l
18 Was non real property included in purchase? ❑ Yes ❑ No (If yes, enter amount and attach itemized list) ........... 18 $— _ — — — —i 00
19 Adjusted purchase price paid for real estate (line 17 minus line 18) .... ..... ..... . .................. 19 $ 250 100
Under penalties of p ry, I declare hat l have examined this statement and that it is; to the best of my knowledge and belief,
d correct, and that am d authoriz d to si n this statement.
t1
Si
hereSignature Title Date
c REGISTER OF DEEDS' USE ONLY `
20 Date Deed Recorded
Month Day Year
21 Value of Stamp or Exempt Number ]22
$
Deed Book
23 Deed Page
COUNTY ASSESSOR'S USE ONLY
24 Parcel Identification
28 Agricultural Land
Township
Section
Quar.
Subdivision
Black
Parcel Number
LVG
No. of Acres
LVG
No, of Acres
25- Improved Parcels
Arch Type"
Occ. Code
CC
Quality
No. of Stories
Story Height
Floor Area
Basement
Finish
Garage Stall
Garage Type.
Year Built
Moderhization/Rehab
Miscellaneous
RCN
$ 00
Miscellaneous
Depreciation Study Reason No.
❑ YES ❑ NO
Does land adjoin current operating
unit?
El YES ❑ NO
Irr. Type
Total Acres/Lots
26 Platted Lots
Zoning
Irreg.
Front
Depth
29 Land Value .
29
$ 00
Lot Size
Street Improvement
Site Improvement
30 Improvement value
30
$ i 00
27Should this sale be used in an assessment/sales If no, give nonuseable sales code
ratio study? ❑ YES ❑ NO
31 Total value (line 29 plus
line 30) .
31
l
$ 00
Nebraska Department of Hevenue "rm No. z-14b-bi- mev. iu-co r
Supersedes 2-146-67 Rev. 11-79
COUNTY ASSESSOR —White and Canary Copies NEBRASKA DEPARTMENT OF REVENUE —Pink Copy GRANTEE —Goldenrod Copy
to
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