HomeMy WebLinkAbout913592
NOV-OS-05 11 : 06
FROM-Land Ti tie Company
. -- .
STATE OF wYOHING
COUNTY OF LINCOLN
I,
Charles Dale Nighswonger,
\L/
307-733-6186
T-859 POOI/OOI F-002
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AFFIDA VII'
RECEIVED 11/10/2005 at 10:45 AM
RECEIVING # 913592
BOOK: 604 PAGE: 376
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Being first duly Sworn on oath, depose and say:
That I am a citizen of the United States of America over Ù1e age of 21 years, and a
resident of Volusia, Florida
That I was well and personally acquainted with Harry Nighswonger and Doris L
Nighswonger Trustees of the Harry and Doris 1. Nighswonger Family Trust, dated Ocrober
8,2001, in that certain Warranty Deed dated October 8, 2001 and recorded October 10,
2001 in Book 474 PR., at Page 45S(n the office ofÙ1e Recorder of Lincoln
County, Wyoming.
That I know of my own knowledge Ù1at Harry Nighswonger and Doris 1. Nighswonger,
Trustees in the said deed and mentioned in the
attached Certificates of Death was one and the same persons.
/
~
This Affidavit is intended to terminate the trusteeship of said Harry Nighswonger and
Doris L Nighswonger, Trustees of the Harry and Doris L Highswomer Family Trust, dated
October 10, 2001, in the following described property:
Lot 31 of Grandview Enterprises 2~d Addition to the Town of Alpine, Lincoln County,
Wyoming as described on Plat, Inst:rumem No. 876408 of the records ofÙle Lincoln
County Clerk
Subscribed and sworn to before r,ne tl1Ïs 8th day of November
,2005.
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Notary Public
Cùmmission expires: :j ~~ d--. '(,) '6 'CJ () ~
'~¡~~~~~->-.'../t.~,...;..;;:~.,
I· Monica J. a£tn " Notary Pub¡¡o ~
( -:to .... ~
, County ¡jJ . ¡,11~- S¡utî1.òI ~;
Uocoln ~~4~A Wvo(mn(J ~.
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MV Comrn!ss!óI1 Expires :L::...l..¡L..'u.._ j
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~~
',,,--";ì .[";'''''j,,'~'''''''''''¡ STATE OF UTAH - DEPARTMENT OF HEALTH
1,"-)<.'c:~~~~='IX~' CERTIFICATE OF DEA"fH ,r' n (1 f\ ~'1 ~'1
ilndRules. LOCAl.FIlENUMBER 18-1739 STATE FILE NUt.IBER.· ' ; t: _', rr
L NAME OF DECEDENT FIRST MI[1DlE lAST 2. SEX 13a DATE or: DEATH {Mo, D",y, Yrj 3b lll.1E OF DEATH (24 hr cloCk)
'-----~--.P9-~-~-.~~!~!,~~--.---! ri-~~~19.'l-9~ F en~~~~.r:.!2.!~_'.~004 _ QZ.º~~_____
4, DATE OF BIRTH (Mo" Day, W) '. ,SAGE' Lasl B,nI,"ay ,IF U,tI~ER_.' '~R I ,'FUtlDER 2~HR" 6, BIRTHPLACE (C,')' & Sla'. De Fo,e'gn Counlo'! 17 SOCIAL SECURITY NUMBER
OC t~ 5-,J_~?2_.~__128 ___~___:'":S.L::J~I:JM,ules -"-i_o.~__~~~ s a 5 1_351.:- 3 2:- 612 3
BaPLACE -! HOSPI, TAL (S/iI/US, COde,'~ fOff'frJ'"',i!",.,,pn IY,-',','.' A"LL or tIE, R lOCATI,ONS: II 8b. N.AJ.1E,OF HOSPITAL, NURSING HOME OR OTHER FACILITY ------~'"
~~,~¡~~:; ¡ cX! 1, Inpatient, '. ',"._,'-',' ',-'."';"-·',-';i[] 5 Nursing Home 0 6 Residence (any) (d outsKfe a facI/lty, gNe str".el address Of}cea/iOn),
one) '[]2ERJOulp,,;enl c3,OOA ilJ70Ih"ispee,/Y)__.._ Salt Lake ReglOnal Hospltal
B~;T~Tr;k~R Lcf~NOF OEÃT¡'~--l B~Olut~~f~H----- ..l SURVIVING SPOUSE (,I "ole g'," m.,dan n;~;)~~----
DECEDENT 10, \'/AS DECEDENT 11 MARiTAL STATUS - ~--~'2a DECEOEtH S USUAL OCCUPATIOt (Give J<1()(jof~ork done t2bl<lt'ïr.)'()FSUSïNESSORI'NDUSfRY ~~--
~~~1~g'?¿-~C~~7 0 1 NeIer Marned eX] 3 W¡,jON¡¡d dllllng most of .'Io/J<.lfJg Ide Do NOT en/el/è!ired./
Ci " Yes íXJ 2 No [']2 Ma",ed 0 4 O"o,eed Homemaker 01'1/1 Home
I,
~~~Ë~~~~~~~S;j~~; ~:'UMßER _:_ __ -===--___=1~; ~'~~~OWN OR COM~~ n-; =[~ ~_~~:~ n .. ~~T~~~~~~~~l-~__
Be INSIDE CITY 1131 ZIP COD'i 1.14 WAS DECEtiENT OF HISPANIC ORIGIN? 0 1. Yes [~ 2 No I 15 H}\~E - Black, V.hle, ¡'I(1 16 EDUCMION (spc~Jfy only hig!Jt:S/
Ln.11l 57 (If yes, Sper...lfy) - !nr.Jlan (lnte nH~J be t:lltl'1 ad), grade. comp/dtcd) Elemen!af)' ur
~ Japanese, elc (Specify) Second3fY (0·12) College (13.16
~ 1 Ye$ 0 1 Mexu:an 0 2 Cuban or 171-)
CJ 2 No 83128 [J 3 puerto R,can lJ 4 othe'ISp'ClI,1 vi h it e 12
17, FATHER'S tjAME (First. Middle, 18. r.1AIOnl nA.ME OF MOTHER (First, Middle, Last)
PARENTS
Max Hill iam Sti
t~arie Thomas
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INFORMANT
Bill Nighswonger, son, 217 South 800 East, Salt Lake City, Utah 84102
8 :'::?:':~':'~;~~~;;~~~ ;";; "1 ";.:"::~{;;:~';C::::;:. ''"OM "~:::::. :',',:"' ....
22, SIGNATlI ¿zYNERA~jÞJ}~ ' 1235 L{C;~~~~~'~;~~----r~~~~~~ HOME (N~;~~:~a:d';';~r~¡~~~-~---
251.'A~~ID~gW~~:;;}SyY,NgÞ,HYSIC,:¡;AN,126,',.:,,:~,~~,::,1:2;~~'d~t~d~~~ ~~~':':~~¿,~~,~ death reported 10M,E.? 0 1 Yes l6 2 No 205 Sou th 100 Eas t
___j-:..l~~Lc---________~.=--"-A:_ENo _ '. HR--=--"'CJ.=-=-OAY_Y~R___ Brigham City, UT 84302
27a, CERTifIER' . . .. , " "-
¡'Xl 1. CER11F YING PHYSICIAN Tg l~a b~st of my knowledge, dealll occurred at Ihe time, dale. and place, and due to the cause(s) and manlier as staled
¡-l . 2 MEO!CA~ EXAMINERlLAW Ét:FC)RCÜ'IENT OFFICIAL: On lhe basis of examination ard!ur investigation, in my opinion, dealh occurred at the lime, date, place and due to Itle
--" C3use{s) and manner a;¡ slated.
2lb SrlG~î-UREA-NO T~IT-- - CERTIFIER 127~UCENSE NU~~f3ER -~ -----:~----127d DATE SIGNED (.\Iuolh Day Ye~;:¡~
~~ ""-' 1 ";)'Vl l_L<c. -IW~ L~ (~'ctl-
28NAt"f:-ANÔ ADDRESS - P ~ON WHocîRTtFIEOTIiECAUSE OF_ DEATH (Item 31){Type..;Pnnl) -- - - -~ -~-~ ----: ----------~- ~--
J Ô",,(tdu~e. \'=\((}..\ II'~ e. \VI\V\-\;", -o'I..Av-( Is LLI UT 'b'L/¡(jCp
29 REG~'S ~R S SIGf'j~ '- ¡30a DATE REGIS1RAR NOTlF!ED OF DEAfH 130b DArE FlL ED (Al... Day Yr)
,) Lh ; ,u.! (Mo, Day yo A . 1 1 3 2 0 0 4
'ta,{A.~ ,. p r ~ ,
31. PART t ~hT~~ST~:~~g~S;R~~S~~1~6'ckl,\~~:~~~;A;~~~0R~,tf~~S~A~~C~ 6':}~ g;~~~tO~JOE~gl~ ~{/j~ER THE, MODE OF DYING, SUCH AS CARDIAC I ~~~:'~:·~¡~I~SI;::I,~;'
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DISPOSITION
CAUSE OF
DEATH
~;~;F.'~; Zo~2~;nEr~~t~~g , a _ ~ú. V cl~ ç¡ C' A ( y6,.+
in d~a h) . 'b~~TO~O;:A~~~:&O;~St--
~r~i~:~~f~'~ :~\I~~;~,W~t~S, if . .... '.' c.6UE T (aRt A CON~(\E"CE OFI-\- C . \... "--'L.
r:;ì!~1~~~:~!1¡;1!:';i:ci¡~i!;2~~~"~~V(~;::;:Jctl(
~:~,:'~~;\~':.~,~'~~, ;:,F,.~~,.~.<,'~'", f~ª~~~<~~~~~::', '~:¡:;~ ':;':~:~~7~1:¡~!.X~(~::~.
___..:_~~________________________ ._~ I [J 4 Is unknown In ,elat,on 10 rho caus. 01 dealh l
~t;'ANN:'~::OF DÉ~H 2 Acc;d.nl ,~".:.5".'.:D,.A."T, E OF Ir,UURY,. iM~, . D':J35b Wj71~~rlð~~[jŸ- 3ð I~J~:: [Ji~R~r;:':? 13S~~~¿~Eb3rdI\~J~1F(s~Œ~7~1'~-;t'~'f~~--
35e~CAT!Or~-{SIJee/ Dr (wal route nu;;;ber, cdy or t¿;;~~ county a-;;;¡~i~ï~ 3Srlf ~~~~i~¡;;c;d~)t SP~~~Xd~'cûd~r~1 was ·drlver-,n
:~J3, Suicíde 0 4 Homicide ; . ... . pa~s8l\ger or pf!destflan.
-:5. Ur,'d,eterminedD 6- Pending ._~_ .__.__~_______~~_....
__J If 111jured Inv!:!>!¡gaLion 35g, pESç:RIßE HOW INJURY OCCURRED (enlf;r ~equenœ of events which resulted in injury, NATURE OF INJURY should be elll¡;:n:d;/1 í/erq 31)
Purpo~p, y or
Acdd~nt1y
UDH-BVR
Form 12,
Rev. 12/98
This is to certify that this is a true copy of the c<¡rtificate on file in this office. This certified copy is issued
under authority of section 26-2-22pftheUti!h (ode Annoti!ted. 1953 As Amended.
I)Ú/Ul~) ¿ 1{LV~r
Barry E. Nangle
DIRECTOR OF VITAL RECORDS
R'9~I~ 3 ~~ðlll~III~III~11 ~III ~III ~III !IIII~III ~II ~II By
Di!te Issued: APRIL 13. 2004
County
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J).'C/¡J."';:',,,¡;~:,,g,;b~Z STATE OF UTAH - DEPARTMENT OF HEALTH
J:,~ ~!~1~!1~:~~~c: FIlE NUMBER 18-0703 C E RTI FICA TE 0 F 0 EA TH STATE FILE NUI,IeER
1 NN.\E OF OECEDENT fIRST MIDDLE LAST 2 SEX 13d DATE OF DEATIt (Mû Day Yr-;-lJb TIME OF DEATH (24 hr clod)
- -------- Hi3r_ry____I__~ - -- f--- NIGfJS\1QN_G.E:R__ M.9J~ _JFebr:.!lªr:1'-J1LIQQ3..J~l52.9 _____
4 DATE OF BIRTH (Ata Day, y,) J5 AGE- Last BI thday IF UIIDm 1 ì'E:tl.,R I IF Ut,LJER 24 HRS i 6 BIRTHPLACE (City ~ Sla/¿ Dr FOIf:u)t) COl,nlr;) 17 SOCI....L SECURIfY NtH.mER
Mon1Jil---U8¡S Hours MloLi1es I 5 11 18 I' 3 5
~~1!?t~:¡t__Z.7,-~922 _~ __ 8~_~ __ __ _-"'..i_ola_, _~~~a!_ I - _~ ___
aa PLACE: HOSPITAL {stal¡,s Ç1Jdu forllosprlB , '/J'JlALl OTlIER LOCATIONS I' 8b Nt-ME OF HOSP¡fAL NURSlt G HOME OR OTHER FACILITY
g~~¡~~~ I ~X11 Inpatient ¡ [J 5 Nursing Home D 6 Resld~nce (an~) (If pt..!s¡J¿ a faCJ/¡ly 91~,: ::;ff!;:~r øddless of location)
_ ~_I.lJ~~'.'.ulp~'''nl Lë~~--19 ",-O~'er{ÓP~"'Y)_ _ ~____ _____ L..lJrl.I,:,:rs i t'y_..!.jOS£,i.!.a~_~_ __~_____
8e CITY TO\NN OR LOC~TION OF DEATH 8d COUIHY OF DEATH ¡ 9 SURVIVING SPOUSE (d ~~¡{e give maiden nðme)
Salt LakeC1ty Salt Lake ~ Doris Stinson
DECEDENT 10 wÃs OECEÓENT J'11 MARITAL STATUS 112a OECEOEt T'S USUAl OCCUPATION (c;e J<md ¡:;¡;:;;;¡;dGf~ , 2;- Kït DOFãUSltIËSSORltiÜUS1RY-~--
EVER IN THE U S -] 0 diJnng most of \.orxml} Me Do NOT enter leflred) L
ARMED FORCES? L 1 Neier Martled 3 Widowed
~J 1 y" [] 2 No I?:J 2 Mamed 04 D,,"'cod H,mufacturing Engineer Aerospace
13;RESIOEtjëE-=sTREE, T-AND"UMßÊR---~-- - -1130, CITY, TO'/,n, 'JORCor,IMUt~ 'f13c. COUNTY --~ 1'13~,d STATE-"
637 Mountain Drivel Alpine ~ Lincoln Wyoming
13;ItJSIDE-C1l13f- ZIP CODE-¡14- WAs DECEDENT OF ~P-MJiC ÕRIGltn -[J1.-y-;s -~Ul~- RACE - Black, I¡'¡hile" ~~--rŠ-- EDUCÀ~N(,P;;C¡;;;-"-;;¡;h¡gl,~;¡
LIMI1 S1 (dyes, Specdy) - Indian ((Jibe mal' be entered), I g.-ade r..:-omp/eted) Eleml:.!nl<:J.ryor
,,1 83128 -- Japanese, elc. (SpaUr}') S",,:ol1dary (0-12) Collegl:.! (13,16
~ 1 Yes lJ 1 Mexican 0 2 Cuban Of 17-0-)
02 No 0 3PuertoR¡can 0 4 Other (SpbClfy Caucasian 12
17 FATHER'SNAME (First, Middle, Last)
Harry M. Nighswonger
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PARENTS
118 r.tAIOEt NAr.1E OF MOTHER (First, MidJle, Last)
I Elnora Paisley
INFORMANT
19 NAME, RELATIONSHIP Arm MAILING ADDRESS OF INFORMANT
\.JIFE: Doris Nighs\vonger / 637 NOl1ntain Drive / Alpine, Hyoming 83128
20. METHOD OF DISPOSITION
21 a, DATE OF D¡SPQSITjOtl 21b, PLACE OF DISPOSITION (name of cemetery, 21 c LOCA nON _ Cil¡' cr Town, Slale
crematory, 01 OflltH place)
_ ~:::~~~bmenl~:?:~~:B :::::: ~~_~_ ~:~uj ~!Ye_=--~~em~~o_r~___ ~ _:d~I~u:a:l ___
2~ ATURE OF FUNERAl SERVICE LICENSEE r23 UCE/ SEE NI rMBER r24 FUNERAL ¡ tOI.IE (Ni:Jfne a Id dc/dress) - ~ --
,::ij~ ¿..~ 5190244-0902 Hyers Nortl1ary-l01696
_5 DATE OECEA SED WAS ";s7 , 126 If not ctJr1ífied by rJ1,ediCal e,(iJminer, was death r..ported to M,E 7 LJ 1 Yes fXJ 2 No 205 Sou t h '1 00 Ea s t
AnENDEDBYCERTIFYINGPHYSICIAN ItY8s,enlerlhedateandhouuepofled. Brigham Ci ty) UT 83L.02
February 18,2003 ME CASE NO, HR___^10_DAY _YEAR
-----,-----_._'-----..,.-----------------._-,~~--_.._---_._._- ._-----~----.","-
27a, CERTIFIER
¡X-! " CERTIFYING PHYSICIAN' To Ihe "e.' of my knowledge, de"h occ,"'f'd allhe"",e, d,te, and pla'e, and due 10 II" ,"u,e('1 and n"nn" '''''',d,
r-J .';2, MEDICAL EXAMtNER/LAW ENFORCEMENT OFFICIAL: On the basis ot examination and/or in;¡es!igf.ltion, in my opinion. death occurred at tl16 time, dala, place arid due 10 tha
"-- ~s) and manner as taled
______ _~~ ~Tln6e: E TIFf:~_ =~-, ~~~_= l(fl£Ilqëf&-Q=l{JQ~27d~~D:qlQ3.-~~~~
F PER N VJHO CERTIFIED THE CAUSE OF DEAl H (Item 31) (Type/Pnnl)
CERTIFIER
Dr. Rand Jensen MD. O. NOrth Dr' alL.L.akp City Iltal:L..£li¡]3?
29. REGI~TRAR'S SIGNATURE '~ L.ø.. ~, . /:? II I· 30a, DI>.TE REGI$l RAR NOTIFIt:O OF DE-A, fH I; 30b. DATE FILED (Mo" Day, Yr.)
~~L/<..:2:tVc;.. (Mo. Day. YO February 20, 2003
31.PART I. ~~T~~sr;I ~g~s;~R~NsJ~~t~6c~~ g~~~:;~c ~ ~~~sR~ìi~;S~A~~t~ 6~ ~ ~¡~~~ o~OE~~t~ ~;~1EH THE MODE OF DYHiG, SUCH AS C,~ROIAC ¡ ~~~:~~:~tl~s~~t:~~:!
l'{¡~\\,v1"jŒlSl(M
DUE T3J-0R fS A COIISEQUEII OF', II!<L-<' I
_-----.d:0.'k11{ l£l.TI2.~
. DUE TO lOR AS" t COIISEQUENCE OF) ,
SLLSi(iMJLLc..JÆllliatWl4~:húb.4-
DUE TO (Or{AS A COIISEQU, ENCE 0?J I" IL , '
(l^ec~fMJ~~Vf~L1Ll' V(
IMMEDIATE CAUSE (Final
disease or condition resulting
in dea,h)
I;EÛV-1--
! 2l..1vtL_
I
!?_t{l]~
II ý !¡J~J _~
Sequentially lisl conditions, if
any, leading to imrnediate
cause Enler UNDERLYING
CAUSE (disease or injury that
Initiated events resulting in
dealh) LAST
PAHT 11 Other Srgnfficanl CondItions contnbullnþ to de<llh ~2 IN YOUR OPINION TO[)ACCO USE BY THE DECEDENT 133a ~\ \S AN AUTOPSYf;3D 1f.ERE AU ropsy
bul no~ ,:ul"n~~ und"'y,ng oau,e g"en ,n an I ~ 1 pmb:":' 'onl':~,ed I~:~au'e 01 dea~h -- [J :- NON-:::- - - ;ERF;~MED?-- -- ~;.:~ ~~ ~~:'~:~~ON
D 2 Was ItlE:! underlYing cause of death OF CAUSE OF DEA TH?
- Old not contrlbule to the cause of death 0 6 W ~~~O:IN 0 1 Yes ŒJ 2 No [J 1 Yes D 2 No
IlJ 4 Is unknown In relation 10 th~~ealh __~~ __ __ ___ ~ _~_ ___ _~___
3Sa, DATE OF III JURY (Mo" DdY. YfT!35b' TII.IE OF IIUURY 35c INJURY AT WOftK? 35d, PLACE OF H JURY _ At home, la"", ,t,,,t. I.clor¡,
.. _L (24 Hour Clock) [] 1. Yes [] 2 No office, bUilding, etc, (specify)
35e, LOCATION (Street or rural route lIumbe;', city or lown, county ~~-~ 35f~lr motor vet~I:;_~;;;-d~·;¡"~-p~"~¡fyit d;c;d~·~ï~~;s d~~.;;¡'
pilsseng~r cr p~d&slrran"
o 2. Accident
~J3:.~ujdd~ [] 4.I omidd~
í--J s· U~detennined D 6. Pending
-~ If 1(1 lJred. Invesligation
Purpo~ely Of
Acciqently
35g DESCRIBE HOW INJµRY qCCURRED (en/sr St,;( ui!/Jce of events which resulted in injur¡, NATURE OF INJURY Sl~~;;¡;;;;;¡;;¡¡;;;;'---;¡¡---"
This is tocertify that this is a true copy of the certificate on file in this office, This certified copy is issued
yncjer é!i..Ithority of section 26-2-22 of the Utah Code Annotated, 1953 As Amended.
Date Issued:
County
!3 ~ ¿ 1tcµYL-'cglsù
Barry E. Nangle
7~ðIIIIIIIIIIIIIIIIIIIIIIIIIÏilm¡'~~ i~ Illr nEC~:DS
I' 2 3 4 3 6
ltí; 2003
Salt Lake