PROBATE COURT OF LAKE COUNTY, OHIO MARK J. BARTOLOTTA, JUDGE ESTATE OF __________________________________________________________ ,DECEASED CASE NO. ______________________ CERTIFICATE OF TRANSFER NO. ________ [Check one of the following] Decedent died intestate. Decedent died testate. Decedent died on ______________________________________________ owning the real property described in this certificate. The persons to whom such real property passed by devise, descent or election are as follows: _________________________________________________________________________________________________ Name Residence Transferee's share Address of decedent's interest _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ [Complete if applicable] The real property described in this certificate is subject to a charge of $___________________ in favor of decedent's surviving spouse, ______________________________________________________ in respect of the unpaid balance of the specific monetary share which is part of the surviving spouse's total intestate share. 12.1 - CERTIFICATE OF TRANSFER Amended: March 1, 2014 American LegalNet, Inc. www.FormsWorkFlow.com (Reverse of Form 12.1) CASE NO.______________ The legal description of decedent's interest in the real property subject to this certificate is: [use extra sheets, if necessary]. Prior Instrument Reference: Parcel No: This instrument was prepared by ______________________________________________________________________ ISSUANCE This Certificate of Transfer is issued this _______ day of _______________________________________, 20_________. __________________________________________________________ Probate Judge AUTHENTICATION I certify that this document is a true copy of the original Certificate of Transfer No. _____________ issued on _____________________________ and kept by me as custodian of the official records of this Court. ________________________________ Date ___________________________________________________ Probate Judge By ________________________________________________ Deputy Clerk 12.1 - CERTIFICATE OF TRANSFER PAGE 2 Amended: March 1, 2014 American LegalNet, Inc. www.FormsWorkFlow.com