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AFFIDAVIT OF SURVIVORSHIP
STATE OF WYOMING )
) SS.
COUNTY OF ALBANY )
RECEIVED 8/24/2005 at 10:37 AM
RECEIVING # 911204
BOOK: 595 PAGE: 560
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, VVY
Tracy Sidella Nicholas, being of lawful age and being first duly sworn according to law, on
oath deposes and states:
1. TraCy Sidella Nicholas is the mother ofKaitlin K. Nicholas, deceased.
2. By Warranty Deed dated November 5, 1980, Tracy Sidella Nicholas and Kaitlin K.
Nicholas (misspelled in the Warranty Deed as Kaitlan K. Nicholas) became the owners as joint
tenants with rights of survivorship in the following described real property:
Beginning at a point 1/8th of a mile east from the SW comer of the
SE¼ of the NW¼ of Section 11, T35N, Rll9W, on the southern
boundary and running 1/8th of a mile east, thence 1/8th of a mile plus
209 feet north, thence 1/8th of a mile west, thence 1/8th of a mile plus
209 feet south to point of origin, containing 13 (thirteen) acres more
or less.
The Warranty Deed was recorded November 6, 1980, in the Office of the Lincoln County Clerk and
Ex-Officio Register of Deeds at Book 170PR, Page 165 as Document # 548183.
3. Kaitlin K. Nicholas died December 20, 1999, at Joplin, Missouri, and left surviving
Tracy Sidella Nicholas, the affiant.
4. Attached is a certified copy of the Death Certificate of Kaitlin K. Nicholas.
5. The death of Kaitlin K. Nicholas terminated her previous estate in the above-
described real property.
6. Upon the death ofKaitlin K. Nicholas, the affiant, Tracy Sidella Nicholas became the
sole owner of and became vested with complete title to the above-described real property.
7. This Affidavit is made pursuant to and for the purpose of the provisions of Section
2-9-102 of the Wyoming Statutes.
DATED this ,~ ~-~day of ~<j ../t_ ,2005.
Tracy Si/della Nicholas
Affidavit of Survivorship, Tracy Sidella Nicholas
Page 1 of 2
'00561
STATE OF WYOMING )
COUNTY OF ALBANY )
The above and foregoing Affidavit of Survivorship was subscribed and sworn to before me
by Tracy Sidella Nicholas this ,~ day of fir~-~ ,2005.
Witness my hand and official seal.
N(~ublic
Affidavit of Survivorship, Tracy Sidella Nicholas
Page 2 of 2
TYPE/PRINT
'" 09 1204
PERMANENT
BLACK INK.
FOR REGISTRATION DISTRICT NO.
INSTRUCTIONS
~ O3~IER SIDE
;~ND HANDBOOK.
MISSOURI DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
.EG,STRAR'SNUMSER f'
-00562
STATE FILE NUMBER
124 -
1. DECEDENTS NAME (First, ~z&~14. Last) 2. SEX 13. DATE OF DEATH (Month, Day. Year)
IC~qY,TN ~ 1~(3~01~ F~m~le I ~c~m~r 20, 1999
4. SOCtAL SECURI~ NO.
5a. AGE-~st 5b. UNDER 1Y~R ~. UNDER 1DAY ~6. ~TEOFBIRTH(M~th, Da~YeaO ~7. BIRTHP~CE(C~dStateorForeignCount~)
Bi~y (Yea~)
I I ~g. 20, 1979 O,adalaj~a, ~co
326-76-7392 ..............
U.S. ARMED FORCES? 9a. P~CE OF O~TH (Ch~k only ~e; s~ inst~tions ~ o~er si~)
~Yes ~No ~Unk. HOSPITAL: ~lnpatient ~ E~Outpaflent ~ DCA OTHER: ~ Nursing Home ~ Residence ~ O~er (Specie)
9b. FACILITY NAME (If not institution, give street and number)
CITY. TOWN, OR LOCATION OF OEATH
Jop] in
Fred,man Hospital West
10. MARITAL STATUS - Married, Never 11. SURVIVING SPOUSE'S NAME
Marded, Widowed. Divorced, (S~.ify) (If wile, give full maiden name)
Never Married ,3b. cou.TY None
13a. RESIDENCE - STATE
Kansas . Riley
13e. STREET AND NUMBER
2215 College Avenue
14. WAS DECEDENT OF HISPANIC ORIGIN
12a. DECEOENT'S USUAL OCCUPATION (Give kind of 12b. KIND OF BUSINESS OR INDUSTRY
work done during most of vvork~g life. Do not use retired)
SD~d~nt C~33 ege,3d, z,P CODE
13c. CITY, TOWN. OR LOCATION
Mmnhattan 66502
13f. INSIDE CITY LIMITS 13g. YEARS AT PRESENTAtDRESS
1 2 t 3
[~ Yes [] NO ~ Under 5 [] 5-9 [] 10-19 ~-~ 20 or more
(Specify No or Yes - Il yes. specify Cuban, Mexican. Puerto Rican, etc.) 15. RACE - American Indian, Black, White, etc.
(Specify) 16. DECEOENT~S EDUCATION
I
(Specify only highest grade completed)
0
17, FATHER*S NAME (First, Middle, Last) I 18. MOTHER'S NAME (l~rst, Middle, Maiden Surname)
John Nicholas . I ~racy Metcalf
1ga. INFORMANT'S NAME ('rype/Print) 119b.MAILING ADDRESS (Street and Number or Rural Route Number, City or Town, State, Zip Code)
Dr. John Ni .cJ~olas I 110 S. Windwood Carl Junction, M~.~souri 64834
20a. BURIAL, CREMATION, 2(70. DATE OF DISPOSITION J 20c. PLACE OF DISPOSiTiON (Name of cemeler)5, crematory. Or 20d. LOCAT ON - C by or Town State
OTHER (Speciiy) (Month, Day, Year) other place) '
Crmnmtion IDec. 21, 1999 IChappel Crematory I Webb City, Missouri
a,. S'GNATURE OF FO"E~- SERV,~L,CENSEE oaa~a_~ ACT,NQ AS su~a ~ } ~ ,l=a' "AMS AND A"DRESS OF FAC,L,TY PAEKEI{ I~RTUARY~.~. { 22b. FUNERAL ESTABLISHMENT
· ' Lis on y on;~c~%°s; .... I~ line ~,l I~ , ~, , ' , __ ' ^ P' y . sock, or heart fail .... Approxi .... ,nterva B .....
·Onset and Death
ON OTHER SIDE
cond~l~on resulting
in death) [ b.
Sequentially Jlst
conditions, if any,
leading to immediate
cause. Enter c.
UNDERLYING CAUSE
(disease o~ injury that
init~ted events resulting
in death) LAST d.
DUE TO (OR AS A CONSEQUENCE OF):
DUE T/~(OR A.S~, CONSEQUEhJ(~ Of):
DUE TO (OR AS A CONSEQUENCE OF):
PART IL Other ilgnificant ¢ondltlonl contributing lo death but not resulting in the underlying cause given in Part t. 124.PREGNANTFEMALEIF DECEASED10_49,1N WASTHEWASLAsTSHE 25e. WASpERFORMED?AN AUTOPSY 25b. WEREAvAiLABLEAUTOPSYPRioRFINDINGSTo
I 90 DAYS? COMPLETIONDEATH? OF CAUSE OF
[] Yes ~ 1 1 2
[] Unk. [] Yes
[] Yes [] NO
NO
26. MANNER OF DEATH 27a. DATE OF INJURY J27b TIME OF 127c. WAS INJURY ALCOHOL- 27d INJURY AT WORK? 27e. DESC~BE~OW INJURY OCCURRED.....,.~?
~ (Month, Day. Year) I INJURY I RELATED? (N~.[W~fedlo [] Yes {~ No [] Unk.
~Accident I I ut m.. ~.o m u.~.
27LP~OE OF INJURY - Al home, fa¢m street, faclor~, office 27g. LOCATION (~reet and Number or Rural Roule Numbe~ Ci~ Ct Town, State)
~ Homicide .
2aa. ¢Spec~&) 2a~. To ~e best ol my knowledge, death ~curred al ~e time, date and place and due to ~e causels) sited. [2aC. DATE maNED / 2ath TrUE OS DEAT~
* CERTIFYING PHY,ICIAN (S/gna,ureandTJt, e) q~~~% y~ ~ (Month. De, Year)
~e2ga' NAME~o~AND ADDRESS~[~OF CERTIFIED ~20~(PflrSlCI~N'~[~[O~~EOIC~L EXAMINER ~OR CORONER) ¢ype~o~or Print) 2gb._ .~o~MO' MCENSE NUMBER 30. WAS~ CASEyes REFERRED~ TO MEDICAL EXAM NE~CORONER?
THIS IS A CERTIFIED COPY OF AN ORIGINAL DOCUMENT.
(~ not accept ff mphotog~phed, or ff seal impression cannot be felt.)
;UMENT IS PROHIBITED BY ~W (sec. 193.245, 193.255, & 193.315 RSMo 1994)
MO 5B0-1103
M
I HEREBY CERTIFY that this is an e~act reproduction of the certificate for the person named
records of the Bureau of Vital Records of the Missouri Department of Health. Witness my hand as County
the Seal of the Missouri Department of Health this date of