Aff - Smith, Clarence_11/21/1994� GIBSf��c;OUNTY DEPARTMENT OF�!EALTH
800 S. Prince St.
Princeton, Indiana 47670
� 812-385-3831
RECORD OFDEATH
THIS IS TO CERTIFY
- that according to the records o
C�l ^.l fT'�l11�}�i��Yl�*i�
Died on 09/30/1977 at '7: pM
Gibson _ ra Hospital
1808 Sherman Drive
Princeton IN 47670
Age at death . 53 Years Sex: M
Marital Status: Married Color: White
Cause of death: Cerebral Hemorrhace
Signed by: James F. Peck, M.D.
Princeton IN 47670
Place of burial Walnut Hill
or removal:
Ft. Branch ZN 47648
Date of burial: 10/02/1977
Funeral home:
S .., !i L
Stodghill Funeral Home
304 47. Locust
rt. Brancli IN 47648
Department of Health,
Signed by v,irts�a6G �,�wY
Gibson County Hea Commissioner
Oakland Citv, Zndiana 11/17/94
Address Date
Recorded locally in Book No. Page No. 49 Fi1ed: 10/OS/1977
STATE OF INDIANA
SS:
COUNTY OF GIBSON
� _�
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AFFIDA IV T OF - -->
HEIRSHIP;OF DOROTRY RRAMER�
. �_ �/
DOROTAY RRAMER, being first duly sworn upon her oath deposes
and says:
1. That this Affiant is an adult sister of Clarence Smith, who
died on September 30, 1977, in the County of Gibson, State of
Indiana.
2. That at the time of his death he owned the following
described real estate located in Gibson County, Indiana, to-wit:
Part of the southeast quarter of the southwest quarter of section
18, township 3 south, range 10 west, described as follows, to-wit:
Begin at a point located as follows: From the intersection of the
south line of Walnut Street in the Town of Fort Branch, projected
eastward, with the west line of U.S. Highway 41, run west 245 feet;
thence south 183.5 feet; and from said beginning point thus
established run west 70 feet to an iron; thence south 183.5 feet to
an iron; thence east 70 feet to an iron; thence north 183.5 feet to
the place of beginning, and containing .30 of an acre, more or
less.
3. That at the time of his death he left surviving as his sole
�—
an �only heirs at law the following:
NAME RELATIONSHIP
Mary Jean Smith
Jennifer Lynn Schroeder
�
Wife
Daughter
. . '• � �
Glenn David Smith Son
Timothy Scott Smith Son
. 4. That there are no Indiana Inheritance Taxes or Federal
Estate Taxes due and owing.
AND
FURTHER
AFFIANT
STATE OF INDIANA
SS:
COUNTY.OF GIBSON
�r�lY�
/ j� NOT.
/� � '� / / /
/ ' l
C i/.' � �� ;' .'l, ji•' C
.. . . �Ct � /. �
Before me, a Notary Public, in and for said County and
' State, personally appeared the above named signatory, who
acknowledged the execution of the same as being true and correct
and the same was signed on the l5 � day of }� �;x-,,.Iw`, 1994 .
� -./' r.
SIGNATURE: �.�-��o-c.�- •�.c.:�<az.4.�;
PRINTED: ,t �•'� �✓� �-1�✓,tt��l �e.c
NOTARY PUBLIC, AND I RESIDE
IN GIBSON COUNTY, IN
My Commission Expires:
�� 1 �.-c,ti.-...l�e,ti. t 6 � � 9 9"5
THIS INSTRUMENT WAS PREPARED BY JAMES G. McDONALD, III, ATTORNEY AT
LAW.