HomeMy WebLinkAbout874697THE STATE OF WYOMING )
) SS. BOOK~_PRPAGE 0~'/
c0U TY op L NCOL
FRANCES JUVAN, being first duly sworn upon her oath, deposes
and states as follows:
1. On the 26th day of February, 2.997, my son, EDDIE JUVAN,
passed away, as is evidenced by the official cernificane of death
attached hereto and incorporated herein by this reference.
2. At the time of his death, my son jointly owned with me a
parcel of real properny, said parcel being located in the County of
Lincoln, State of Wyoming, and more par.ticularly described as
follows:
The Lots Numbered Eleven (11), Twelve (12), Thirteen
(13), Fourteen (14) and Fifteen (15), in Block Numbered
Sixty--one (61), in the Second Addition ho the Town of
Kemmerer, Lincoln County, Wyoming, as surveyed, platted
and recorded together with the .buildings and improvements
thereon.
3. Said real properuy was conveyed by me, FRANCES JUl/AN, to
F ,R%N,,CES JUVAN and EDDIE JUl/AN, as joinC uenants, with full rights
of survivorship, by Quitclaim Deed dated June 8, 1989 and recorded
in the Office of the Lincoln County Clerk and Ex-Officio Register
of Deeds on June 8, 1989, in Book 274PR at Page 284.
O88
4. By reason of my son's death, I became entitled to sole
ownership of the abov~e-described real property.
DATED this !8 - day of _~i~ __., 2001.
FRANCES JUV~- . ......
SUBSCRIBED, SWORN to and acknowledged before me this
day of ~ , 2001, by FRANCES JUVAN.
WITNESS my hand and official seal.
Notary Pu%~ic
My Commission Expires:
· REN'f'CHAK
~J . C~unty of L.trv~tn
2
~f ~, ,i;"i~"? :"~ ¢'':~ %}';~ L;bH I IFICATE OF DEATH
' Local F(te Number
DECEDENFS NAME(FifsIJ : (Middle) tt'a~i) ' ~ ' ' ~EX ' DATE OF DEAT (Monlh, Day,
~. E~E _ ~' · I ~' JUV~ ?~/ ~ ~ Hale ~ February 26, 199i
RACE--Am ..... Indian. Bl~ck IAG~t~UNOE~~E~i BAy DATEOFB ~U(Mm]lh ~a;,Yea~ ~N~~--~ '
.... __._- . .-._ } . ~9 J~. I ~. '- 1 ...... :1~ ~tober 15, 1927 ~L~TIN
HOSPITAL: ~ {hpatienl ~ER/Ou pa e t ~ BOA ) (
~~~- -- . . }THER. [] Nurs[f~g o ~e ~ Residence
FACILITYNAME(/Ho~ ,st,tut,on r, ive, reetand ......... '- ~A ?: ~ ..... [~ Olher
....... / ~CITY, 7OWN, OR LOCATION OF DEATH
~o, ~ZE~ ~E~ ~PITAL
don~ during most of working llfe. Da no~ u~e [aH~edJ ~KIND OF BUSINESS/INDUSTRy ]WAS DECEDENT EVER ]~ u 8.
-,~ ,,. 52~22-6190 J, 2~.~LT~ ~' ],~b. ~IL ~. 8~IC~ Yes
" RESIOENCE~STATE
~COUNTY ~CiTY, TOWN, 0R t. OCAT, O~ ~STREET NUMBER
II~SIDECITY ~ZIPCODE [ANCESTRY Mexican ~uedaRlcan, Cuban, Aldcan, Eng
LIMllS? (Yes or no)
(Specily only highesf grade complefeu]
FATHER'S NAME (First, Middle, LaSll ]MOTtI~R'S NAME (First, Middle Maiden Surname]
'~ INFORMANT'S NAM~ (TypelPfinl) MAILING ADDRESS fSI(eFt and Nu~ bet or Rutal Route ~umbe[. City or T~wn; Slate, Zip Code,
'"..~ JW~ ~,~. 1717 ~I~ER ~. ~ZE~Nz ~ 59715
' ". PLACE OF DISPOSITION (Name ol ~ LOCATION Cily er Town,
METHOD OF DISPOS TION cemetery, cremato~, or olher place) ~ '
" ' ' ' '~' ~burlal [~ Cremation [~ Remove IromS~ale ," . ',
~ 20a. :' ~ Olher(Specily) 20~ K~ER CITM CB~oo. K~BBL~,
SIGNATUREOFFUN~AL~LiCENS~OROTHERPERSONiNCHARGE MONTANA LICENSE NAME AND ADDRESS OF FACILiTY
~' ~~. ~ , ' J ~kken-~lson Funeral 8er
21a. ~ ~-- /~ ' 21b ~ } -'- '
. · r me a~seases, inju~s, or compdc~l[ons Ihal caused ~ne dealh. Do not enler the mode o[ dying, such as car~ ac or resp~ralo arresl A '
shock orheartlallure ~slonl onec / r7 pprox~matelnlerval
Belweeo Onsel arm
. cond on resulting in dealh) . "'- ,. ·
' ' . DUE TO (~ A NCE
Sequentially Iisi conditions if any, ~ b
" leading to immediate cause. Enler DUE TO .OR AS A CONSEQUENCE
Underlying C~use [DJsease~r injury Ihal
initiated evenls r~sult ng n de,th) Last. c ~
d. DUE TO {OR AS A CONSEQUENCE
underlying cause given in P~rt I IAVAILABLE PRIOR TO COMPL ErIC
24a ~ OF CAUSE OF DEATH? (Yes or
WAS CASE REFERRED TO COROK ER? (Yes ornm
25.
26. MANNER OF DEATH · . ' ~DATEOFINJURy [TIME OF iNJURY ~INJURYATWORK? [DESCRIBE HOW INJURY OCCURRED
~N~tural ~J Pending (Month, Day, Ycad '.}'~ [ ~(Yosorno) ' J .
~ Accidenl ~Couldnolbe ~CEOFINJURY~A home l~rm srea acoryo[tice ']~(Slreel end Number or Rurz Rm eNumberOl ~rTow S
' DetermineO ]builalng, etc.(Specify) ' ' ~ , . ~ n. lale)
[~] Suicide ~ Homicide ]21e,
" 28a. TO BE COMPLETE D BY CERTI F~ING' PHYSICIAN ONLY To the bom et my 29a. TO B[ COMPLETE D BY CORON ER ONLY On Ihe ~asls of examlnalion
'
""'""' I , -'-.'
(Signature end, it/e) (Signature a¢~d T/l/el ' ';
DATE SIGNED [Month, Day, Year) ] HOUR OF DEATH DATE SIGNED (Month, Day. Yeao
~ ¢- . HOUR OF DEATH
~ NAME OF ATTENDIN6 PItYSICIAN IF OTHER THAN CERTIFIER (Type or Prin J - DATE P~ONOUNCED DEAB (Month. Day. Yeag PRONOUNCED DEAD
. I(Houd
' NAME AND ADDRESS OF CERTIFIER {PNYSICIAN OR CORON ER) (Type or P[inO
~' .~0: ~. ~ST]LLO~ M.D. 925 H[~ BLVD.: ~TE 12~ ~ZE~N ~ 59715
~AL R~GiSTRAR'S SIGNATURE DATE ~i~ED'(MonlI'L Pay, Year)~
STATEOF MONTANA ) I h~rsby certify that this is a fid], true, and cmTect
) ss copy of the document now on file and of record in
CO~TY OF GALLATIN ) my
, . Witness my hand and Official Seal this
Shslley M; Chefiey, Clerk a Recorder d~y of ~ff~.,Ld~.._, 199~.
Deputy