This indenture, made this _________ day of _________[month], _________[year], between _________, of the city of _________, and sole surviving heir at law of my late deceased daughter [son] _________, of _________, _________ county, in the state of _________, grantor, and _________, being my sole surviving children and my heirs at law in event of my death, grantees. Grantor, in consideration of his [her] love and affection to grantees as their father [mother] and _________ dollars, receipt acknowledged, does by these presents remise, release and quitclaim to grantees, their heirs and assigns, all the following described real estate, being the undivided one-half interest in the _________ acres, more or less, inherited by me as the sole surviving heir at law of my late deceased daughter [son] _________, of _________, to have and to hold to the use of my heirs as grantees, their heirs and assigns forever. I declare and make known that, up to the execution and delivery of this instrument, I am and was the legal and true owner of the lands, and that any written contract, or instrument of conveyance, or any other writing purporting to convey or renounce my title of ownership in the lands as sole heir at law of my daughter [son] _________, is false and fraudulent, and particularly any instrument, writing, or conveyance procured from me since the death of my daughter [son] in favor of _________, whatever their character or form may be, were wholly without any consideration and were signed by me solely through the belief and impression created by them by statements made to me by them to procure that execution, and which statement and facts I find wholly unconfirmed, and that in fact neither _________ nor _________ had any lawful cause or right to any conveyance of my inherited interest in the lands to them without just, fair, and reasonable consideration for its value, and I do now repudiate the validity of any conveyance as they may have induced me to execute with respect to this land.
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