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RECORO YE~+If1E0........i
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BY SURVIVING 5POl1SE ~!Q 3 06 P!I'~~I ;
REGARDIT~iG DECE/~ SE OF ~
~ OTtiCl: SPOU~C 1~YH~RF
PfiL1O: 4'i i' t~AS NEL.D AS
AN CSTATE BY THE ENTIRETY
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~TATE OF n i a _ ~
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COJNTY OF F~•~ ~t.Ii ~I • ~ `
B fore rr,e, a No ry Public, tliis date appcared t97 ~ ~
~Q~ . C_ ~'ti n! , to mc well knowa, who beins by me
first duly sworn, desposes and ~says as follows: ~J , ~
1. That I am the surviving spouse of
2. That my said spouse and myself hcld as an estate by the entircty, _
heretofore acquired title to the fallowing Charlotte County, Florida, property
' to-wit: .
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3. That said C, i,r and C~, A r I eS ~i
were lawfully married to ea h other prior to the acquisition of title
~s zforesaid and remained married to each other without intervening
divorce sp to the time of the demise of said '
4. ~That m id s ouse beca:ne deceased on h~day of L
19 ~ at ~.vc.~,ti~/ County of . Sta of
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5. At the time af death, my sa'Zd~spouse was a resident of the state of
~ t,~ covnty of ,b~ ~r-Z
STATE OF ~ ~ ~ ~
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C4UNTY OF ' ~
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C:1~3'r 3Tl3 £-.2=`S(;l'~hi~~~ L•4'fArC ~?1(' tn7~'~_.iay Af _ ~Q~
at o ~ ~t?.. ~.t.:~ ~~js? r
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, - Notary Public
Thi~ docwnsm p~W*~d by: ~
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My Commission r.x~~ires: - ;
v7(~s~mc~ un.~ Jil~t `ot~na~i.m oI :7loti.:n ~,~'t~llC~J~`/.; - , ~
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10~ 1NCST MANION AV CNUC ~ t i »s~,. ~J~ . i-: . .
•ur~nA o~wow_ r~ow~oA ~ ~ % ' r3~ - T
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o~ ROBERT G. PO~4ER5. JR.
i'~~'~ NofOry PvbiS:, frcn'.::n C~~r•:y, i}^
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` L ~ , rAIYp Cormtisticr~ Expi~es Uecar~ber 26, 1976
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