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, - 1 • <br /> APPLICATION FOR THE ( IllIIIIUUIUIJfl <br /> TERMINATION OF DECEDENT'S INTEREST 8 6 2 7 6 4 1 <br /> I AND CONFIRMATION OF APPLICANT'S INTEREST IN PROPERTY Tx:8499506 <br /> KRISTI CHLEBOWSKI <br /> DECEDENT'S NAME DATE OF DEATH DANE COUNTY <br /> HELM ,t AE DESikETCH-} i!20 / I3 REGISTER OF DEEDS <br /> ADDRESS OF DECEDENT AT DATE OF DEATH CITY ST ZIP <br /> i/ 8y STitre K4 ?3 eA-mrvrzioi-= WT 5352-3 DOCUMENT # <br /> 5037376 <br /> PRESENTATION OF DEATH CERTIFICATE <br /> 11/12/2013 10:05 AM <br /> I certify that I have viewed a certified copy of the decedent's death Trans. Fee: <br /> certificate. <br /> /�fj�/��,,,f _11CC',.• Exempt#: <br /> __ _ t�JtC(JY��•Ci. 0_ �`b 3 Rec. Fee: 30.00 <br /> REGISTE F DEEDS SIGNATURE DATE Pages: 2 <br /> THE INTEREST OF THE DECEDENT IN THE PROPERTY NOTED HEREIN Name and return address: <br /> IS HEREBY TERMINATED/CONFIRMED UNDER THE FOLLOWING STATUTE: R�1R <br /> (please check appropriate statute) �-O r . <br /> 867.045 which pertains to real property in which the decedent was a point R�iN /14(0: OcSTi�'oci'S�( <br /> Tenant, had a vendor's or mortgagee's interest, or had a life estate. (You must 6SIO GA14/JDT(ir0/J PLAZA <br /> provide a copy of the document establishing interest in the real property ) SUITE 314- 2 <br /> ❑s. 867.046 which pertains to property of a decedent specified in a marital �3 <br /> property agreement, survivorship marital property, or a third party confirmation, or <br /> a nonprobate transfer on death as described in s.705.10(1). <br /> (You must provide a copy of the document establishing interest in properly.) <br /> Parcel Identification Number <br /> Presentation of recorded document establishing Interest in real estate. SEND TAX STATEMENT TO: <br /> DOCUMENT# VOLUME/REEL PAGE/IMAGE RECORDS/DEEDS 0giC of a.-34t--gg')s—q <br /> LHssagq g <br /> otV oil z -3 - 8 so -(c. <br /> Description of the real estate. XSee Attached <br /> rlab M <br /> Description of personal property(If any)being transferred. <br /> You may list savings accounts, checking accounts and securities on attached pages. Indicate person(s) receiving property. <br /> DECLARATION: I(We) declare that this document is, to the best of my(our) knowledge and belief, true, correct and <br /> complete and is in conformity with the provisions and limitations of the Wisconsin Statutes. <br /> 1 Name and Address Applicant's Applicant Signature <br /> (List all remaindermenf I Interest In Property (Notarized) Date <br /> beneficiaries If more space is (la: spouse, r•mainderman, (Print or type name below signature) <br /> needed, attach pages ) beneficiary) <br /> at <br /> ! 11 g� N-w'( '13 eh kw r4 rJ 1( !//411/3 <br /> r t 1 ocTE �z cis 1 Z K O <br /> This document was drafted STATE OF WISCONSIN, County of AK)C <br /> by (print or type name below) Subscribed and sworn to before me on NaUEMb //, . 6 3 --- <br /> tit ict{REtii 5 05TR0011a by the above named person(s): SR C t„• ae5%� I Cµ <br /> NOTE: SEE DIRECTIONS. Signature of Notary or other person �jA "�) ``� <br /> Wisconsin Register of Deeds authorized to administer an oath (as per /r/lr X �i �� <br /> Association Form HT-110 5 706 06: 706.07) C.� <br /> Website Version osizoto Print or type name mi f C ALL 5. Dw o cz5 k— <br /> Title AQf n �. Date Commission Expires 3 a7//7 <br /> THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. <br /> PRorcr i D <br /> 3070 -Do a( lvi SC *s,5(#i Cter. OF TgAk.1sPa r14Tc P4gcEL- 14°. 77 <br /> C,1). <br />