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STATE OF
.
COUNTY OF ~
Before me, a Notary Public, this date appeared
, to me well known, who being by me first
duly sworn, deposes and says as follows~:
1. That I am the surviving spouse of '
.
2. That my said spouse and I, as an estate by 'the entirety, here-
tofore acquired title to the followin ~
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County, Flor.ida, property, to-wit:
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p~o~o S ~D ~-rl ~ , ~ .
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3. That my said spouse and I were lawfully married to each other prior
to the acquisition of title as aforesaid, that ?~e remained married
to each other, without an intervening divorce,.up to the time of
the demise of my said spouse.
4. That my said spouse became deceased on the.~day of
.
19~, at , Cour~ty of
. it z v
State of
5. At the time of death, mv said spouse was a resident f the State
of ~~d•~J~~_) , County of _~~.f ~ ~ ,
6. That a copy of the death certificate of said decedent is attached
hereto and made a part hereof. .
,
~ -
~ Sworn to and subscribed before me this .
~ . ~ ~day of s 19
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~ otary P b ic - St" ;te :p ~
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~ I+fy Commission Expires: . ~ " .
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~ Ap3L~ R~CORDED r~or,er ~~'.K STATF Of FLORIQA AI LokG+ D -
~ MY COMl~NSSIOM EXPIRES SEPT 6 1980
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