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AFFIDA VIr
I,
Rolf A. Funk
RECEIVED 10/12/2005 at 9:52 AM
RECEIVING # 912666
BOOK: 600 PAGE: 772
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
· being first duly SWorn on oath, depose and
STATE OF WYOMING
COUNTY OF Teton
say:
That I am a citizen of the United States of America over the age of21 years, and a
resident of Lincoln County, Wyoming
That I was well and personally aCQuaint~d with Nora M. Funk
certain Wan-anty Deed recorded November 12, 1996 , Book 390 PR
387 ÌI1 the office of the Recorder of Un coIn County, Wyoming.
in that
at Page
That I know of my own knowledge that
deed and Nora Marie FUnk
Certificate of Death was one and the same person.
Nora M. Funk in the said
mentioned in the attached Certified Copy of
This Affidavit is intended to terminate the joint tenancy (the life estate) of
Nora M. Funk in the following described property;
! /
Lot 3 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.
State of Wyoming,
.~
~/
Teton County ss.
Subscribed and sworn to before me this 22nd day of
September ,2005
Nod),~(Øt¿
'd' , Jackson
Resl ~g .In: . 9/12/2007
Commlss1or¡ expires:
LAURIE CaE - NOTARY PUBLIC
State of
County of Wyoming
Teton
My Commission Expires 9/12/2007
TYPE
OR PRINT
IN
PERMANENT
BLACK INK
HEAT1f
OCCURRED IN
INST!IUTlON
SEE HAN0600K
REGARDING
COMPlETION Of
RESIDENCE IItMS
. . .
CONDITIONS
IF ANY
WHICH GAVE
RISE TO
IMMEDIATE
CAUSE
STATING THE
UNDERLYING
CAUSE LAST
4
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". ". .STAT,E,Of NEVADA - DEPARTMENT OF HUMAN RESOURCES
\0 ~ '~;,,:,: ìßlbh>N OF HEALTH - SECTION OF VITAL STATISTICS, .:] 0 0 77 3 0 Or 6 r:
I CERTIFICATE OF DEATH I" " 2 J I
1
Ü91086?
LOCAL FILE NUMBER
DECEASED-NAME Arst
Middle
Last
DATE OF DEATH (Month, Day, Year)
3b. Las Vegas
RACE-(e.~" White, Black, American
Indian, etc.) (Specify)
5. White
STATE OF BIRTH
(It not U.S,A., name counlry)
9a. ant ana
SOCIAL SECURITY NUM8ER
3c. 3017 Childress Drive
Was Decedenl of Hispanic Origin? Specify 0 yes G no If yes,
specify Mexican, Cuban. Puerto Rican, etc. A
6,
CITIZEN OF WHAT COUN- Oecedenl's Education.
TRY grade compleled.
9b. U. S. A. 10. 12
USUAL OCCUPATION (Give Kind of Work Done During Most 01
Working Life, Even If Retired)
14a,
MAIDEN NAME
(Street or R.F.D, No., City or Town, Stale, Zip)
83'28
Slate
DDRESS OF FACILITY
Pall ftortuary - Cbeyenne
A.M.
PRONOUNCED OEAD (Hour)
8:20 A.M.
22e. AT
LICENSE NUMBER
MPH, Medical Exam., 1704 Pinto Lane, Las Vegas, NY 23b. 880
DATE RECEIVED BY REGISTRAR (Mo" Day, Yr,) DEATH DUE TO COMMUNICAlILE DISEASE
4b, [APR 3 0 2004
24c,
NO~
YESO
PART
I
Ca) Arteriosclerotic cardiovascul
DUE TO, OR AS A CONSEQUENCE OF:
).)
disease
Interval between onset and death
Interval betwcen onset and death
(b)
DUE TO, OR AS A CONSEQUENCE OF:
In(erval between onset and death
PART
II
(c)
OTHER SIGNIFICANT CONDlTlor~S-Condillons contribuling 10 dealh but nol resulting in the underlying cause given in Part 1. AUTOPSY
ACC., SUICIDE, HOM., UNDET.,
OR PENDING INVEST.
;Specily)
28a.
INJURY AT WORK
(Specify Yes or No)
28e.
26,
(Specify WAS CASE REoFERRED TO
Yes or No) CORONER./~pecify Yes or No)
No 27, xes
DATE OF INJURY (Mo" Day, Yr.) HOUR OF INJURY
DESCRIBE HOW INJURY OCCUR REO
28b.
2ee,
M 26d,
LOCATION.
STATE
PLACE OF INJURY AI home, farm, street, factory, office
building, etc. (Specify)
STREET OR R.F.D. No.
CITY OR TOWN
281.
28g,
ST'\TE'lEGISTR.l\R
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 OF
COUNry-· 'HEALTH
WITHOUT THE
THE CLARK
DISTRICT
By: (V
DONALD S. KWALICK, MD, M.P.H.
Registrar of Vital Statistics
.-)
c.;
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E AL"'(-
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CLARK COUNTY HEALTH DISTRICT
625 Shadow Lane P.O. Box 3902
Las Vegas, Nevada 89127
702-383-1223
Tax ID# 8.8..;.,(.)),51573
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Date Issued:
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MAY 0 3 2004
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