B111 L54 S1-2-ride oT `^
DATE OF INSTRUMENT:
July 6, 2020
AFFIDAVIT
RELEASE OF OWNERSHIP
I, Jackie S. Clark, legal owner of the gravestone located on Grave Spaces 1 and 2, Lot No. 54 in
Block No. 111 of the Blair Cemetery relinquish any rights I have to the gravestone and certify that
none of my legal heirs want ownership of this gravestone. I further authorize the City of Blair to
remove the gravestone from Grave Spaces 1 and 2, Lot No. 54 in Block No. 111 of the Blair
Cemetery.
Jacl I
S. Clark
STATE OF NEBRASKA )
) ss
COUNTY )
The foregoing instrument was acknowledged before me on , 2020 by Jackie S. Clark.
NOTARY PU6LIC
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218 South 16th Street • Blair, Nebraska 68008 . 402-426-4191 • Fax 402-426-4195 • E-mail cltyofblalr@cl,blalr.ne,us ..��,.