Aff - Mounts, Mary Jane_3/14/1980Tr.e affil:v�t furnished snoulr. ba si�ilar :c r.ne fcllowing:
STATE 03' NDI:.��:�
COl'iTY OF _�i/y�) SS :
AFFIDAVIT FOR TRANSFEF OF ASSE'fS
[JITHOUT ADMI�IS'fRATIUN
//litc.� / , being firsc dUly sworn upon ���
oath depos and says: �
1. Tha L' ^2vv��L� died on thc � day of
� 19�y(�estate), (intestate) while domi-
cile in /�'f,/�,� Coun[y, Indiana.
Z. '!hat no petition for the appointment of a personai repre-
sen[ative of his estate is pending or has been granted.
3. Tfiae forty-five (45) days have elapsed since the death of
s:id decedent.
4. The value of [hc gross nrobate escate less liens and encmn- �
brances thcreon does not excced f:ive [housand dollars ($5,000).
t
5. Tnat this affiant is a(wid:w) (widower) (distributee) o�
said decedent and is entitled to receive witfiout administra-
tion the following listed property from the person, firn or
corporation listed opposite�said property•subject to the
liens and encumbrances thereon.
KIVD OF WtiERE
FBOPERTI' LOCATED
: .,_
.% �
VALUE
� �.�, N 9
�"56.5'�
LIII�' OR
EN CUt�iB RAA'CE S
IF ANY
NAhff_ AVD ADDRESS OF
PL•RSON, FIR�t OR
CORPORATION HOLDING
PROPERTY OF DECEDENT
,? - 5' � irv
This af:idnvit is made for the purpose of inducing the above named
holders o` said decedent's property to turn said property over to [hi.c� a�-
Yiant as provided by law. �;,�
. ' . :� `- -• .�
�-� G`_
AFFIANT ' - `l : `:
7��-T �`� -i ',+ �
DC��.,o c�,t.�. =.;=_��_ : � `
:�
ADDRESS � ��.___% `=
Subscribed and svorn to before u�e this � day of �QiLG2i 15� \
�.Jn�, .c'/�.+J �.� ��i2i/
�Notary Publ�
':�� Cormnission expires .J�- 8- 80(
'�