HomeMy WebLinkAbout91086731002-
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STATE OF Wyoming
COUNTY OF Lincoln
AFFIDAVIT
)
) SS.
)
RECEIVED 0/~2/2005 at 10:33 AM
RECEIVING# 910867
BOOK: 594 PAGE: 264
,JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, RolfA. Funk, upon being duly sworn and upon oath do say and depose as follows:
That I am a citizen of the United States of America over the age of 21 years, and a resident of
Alpine, State of Wyoming.
That I was well and personally acquainted with, in that certain Deed recorded
11/12/1996 , recorded in Book 390 , of P.R. at Page 387 in the office of
the Recorder of Lincoln County, Wyoming.
That I know of my own knowledge that Nora M. Funk in the said deed and
Nora Plarie Funk mentioned in the attached Certified COpy of Certificate of
Death was one and the same person.
This Affidavit is intended to terminate the joint tenancy (the life estate) of Nora M. Funk also
known as in the following described property:
Lot 4 of Lonesome Dove Ranch Subdivision, Second Filing, Lincoln County, Wyoming,
according to that Plat filed August 14, 2003 in the, office of the Lincoln County Clerk, as Plat No.
251-C.
Executed this 9th day of August, 2005.
STATE OF Wyoming )
) SS.
COUNTY OF ~=tem~/~~ )
On August 9, 2005, before me, the undersigned, a Notary Public, in and for said State, personally
appeared,;_l~b3_~,know~a~gto Ei. iiil~me and/or, ., identified. . to me on the' basis of satisfactory evidence, to be the
person WhOSe nai~-rle ~s suoscrmed to the within instrument and acknowledged to me that he
executed the same.
WITNESS MY HAND AND OFFICIAL SEAL.
Nora. p~l~ic~:): / - _
TYPE
OR PRINT
IN
PERMANENT
BLACK INK
F D~I
OCCURRED IN
RES~ ~
CONDITIONS
IF ANY
WHICH GAVE
RISE TO
IMMEDIATE
CAUSE
STATING THE
UNDERLYING
CAUSE LAST
STATE OF NEVADA -- DEPARTMENT OF HUMAN RESOURCES
0~)[O~"?~ ~ DIVISION OF HEALTH -- SECTION OF VITAL STATISTICS.
---] CERTIFICATE OF DEATH ~-- "' 0 0 2 6
LOCAL FILE NUMBER
STATE FILE NUMBER
DEC~SE~NAME Rmt M;~G;~ Last DATE OF D~TH (Month, Day, Year) ~ COUN~ OF D~TH
~. Nora Marie FUNK ~. April 26, 2~4 ~. Cl~k
CI~, TOWN OR LOCATION OF D~ . HOSPITAL OR OTHER INSTITUTIO~a~ (If not ~ther, give street and num~d If Hosp. or Inst. indi~te PeA, OP/Emer. ~ SEX
J .... __ ~ Rm. Inpa~ent (Sp~i~) ·
~CE~e.g..~,e. Black3b' Las V~aSAm.,.. ~. 3017 Cniidress Drive ~. I~-Female
~Was.~"~°fHispa"~O~gin?S~iN~yes~nolfyes. ~AGE~ast J UNDER1 YEAR ~ UNDERIDAY DATE OF BIRT~ Mo Day Yr)
I~dian, etc.) (S~i~) s~ Mex~, CubaN, PueMo R~, etc. ~ BiMbday (Yea~) MOS · DAYS HOURS · MINS ( ....
s. White s. I~'. 72 17b. ~ 17c. ~ is, Feb 1, 1932
STATE OF BIRTH
CITIZEN OF WHAT COUN- D~nt's Eduction.Sp~ h ghest IMARRIED, NEVER MARRIED, J
(ff nol U.S.A., name count~) TRY gra~ ~mplet~. ~ WIDOWED, DIVORCED ~ SURVIVING SPOUSE (If ~[e. ~e maid~ n~e
9" ~ontana I~b- U.S.A. I~°. [2 (~)~aTr~ed ~2. Eo[~ Funk
S~IAL SECURI~ NUMBER ~ USUAL OCCUPATION (Give Ki~ o~ Work D~e During Mos el I
I WoOing Life, Even if Retired) KIND OF BUSINESS OR INDUSTRY
13.
358-2~-[95e
114~.
~omemaker ~4b. 0~ Home
RESlDENCE~STA TE
COUN~ C~, TOWN, OR L~ATION STRE~ AND NUMBER ~ INSIDE CI~ LIMITS
(Speci~ Yes or No)
15a.
Wvomin~
15b.
'~ '~ncol~ I'~' Aloine 's~. ~ L0n~e O0~e ~rat[ ,se. NO
FATHE~NAME - ~mt Middle Last ' MOTHE~MAIDEN NAME ~ml Middle Last
~' Marius - ,,l-arse" ~.
Kirstine
Petersen
]NFORMANT~AME ~ or Pdnt)
J MAILING ADDRESS (Street or R.F.D. No., Ci~ or Town, S~te,
~p)
'"" Rolf Fu~k - Husband I~' 55 Lonesome Dove Tr~i!. ! ine, Wvomino 83!2~
BURIAL, CREMATION, R~MOVA~ OTHER (S~) CEME ~ bHY OR CREMATORY--NA~4E I L~AT ~ p di~ or ~own - Sate
$~ naT~ ........... ~ ~ (Signature and Title) ~ ~ ,-- // ~ -- ~
-~ .......... {MO., Uay, Yr.) J HOUR OF D~T. ~5 DATE SIGNED (Mo D ~ Yr) /' HOU~6~TH
0z 21b 21c E~ ~ · ~ ~ L
· F · ' I ' 8 ~.. 2 7 ~ ' ~ef. 8:20 A.M.
21d
' ~. o. 4/26/~ 8: 20 A.M.
NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, A~ENDING PHYSICIAN, MEDICAL ~MINER. OR CORONER). ~ or Pdnt.)~e. AT J
UCENSE
NUMBER
~.L~ S~S, ~, MPH, M~ical Ex~., 17~ Pinto L~e, Las V~, ~ir~a" 880
"EGIST"AR ~ J ~ ~ ~ ~ ~ . I DATERECEIVEDBYREGISI.A.(~o..Oay, W.)I DB~DUETOCO~UUNICAB~E DISRSE
' / 'J ' ' lewal ue~weeu ~e[ and d
.h.T (.) ~teriosclerotic cardiovascul~ disease
DUE TO, OR AS A CONSEQUENCE OF;
I · Interval belweon onset and death
(b) :
DUE TO. OR AB A CONSEQUENCE OF:
Interval between onset and death
lc)
:
PaTA. ROTHER SIGNIFICANT CONDITIONS--Conditions contributing Io death but not resulting in the underlying cause given in Part 1. AUTOPSY
(Specify I WAS CASE REFERRED TO
I Yes or No) CORONER.[~pecify Yes or No)
ACC., SUICIDE, HEM., UNDET., DATE OF INJURY (Mo., Da), Yr.) I HOUR OF INJURY 26. No 127. Les
OR PENDING INVEST. '
I
DESCRIBE
HOW
INJURY
OCCURRED
28b. I 28c. M 28d.
28a,
INJURY AT WORK PLACE OF INJURY--At home.Jfarm, street, factory, office LOCATION. STREET OR R.F.D. No. CiTY OR TOWN STATE
(Specify Yes or No) building, etc. (Specify)
28e. 28f. 28g.
ST,',TE '~ EGISTRAR
No. 265567
"CERTIFIED TO BE A TRUE AND CORRECT COPY' OF THE DOCUMENT ON FILE WITH THE REGISTRAR OF
VITAL STATISTICS, STATE OF NEVADA." This copy was issued by the Clark County Health District from State
certified documents as authorized by the State Board of Health pursuant to NRS 440.175.
NOT VALID
RAISED SEAL
COUNTY., HEALTH
WITHOUT THE
OF THE CLARK
DISTRICT
'-CLARK COUNTY HEALTH DISTRICT
625 Shadow Lane P.O. Box 3902
Las Vegas, Nevada 89127
702-383-1223
Tax ID# 8 -0. - 1573
DONALD S. KWALICK, MD, M.P.H.
Registrar of Vital Statistics
Date Issued:
MAY 0 3 200