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THE STATE OF UTAH )
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THE COUNTY OF S~ I¡-- éjir-l", )
RECEIVED 11/14/2005 at 4:03 PM
RECEIVING # 913685
BOOI<: 604 PAGE: 650
JEANNE WAGNER
LINCOLN COUNTY CLERK. KEMMERER, WY
AFFIDA VIT TERMINA TlNC ESTATE BY
¡OINT TENANCY
Arlene J. Jackman being of lawful age and first duly sworn according to law, upon my oath,
depose and state:
1. That Max F. Jackman died on October 24, 2004 in ¡\'\urray, Utah.
2. That on April 16, 1984 for valuable consideration Leisure Valley, Inc. by their
Warranty Deed of that date, which deed was duly filed for record in the Office of the Lincoln
County Clerk on June 20, 1984 in Book 215PR on page 231, conveyed unto Max F, Jackman and
Arlene J. Jackman, as joint tenants with full rights of survivorship, the following described real
property, to wit:
Lot 80 of Star Valley Ranch Plat 16, Lincoln County, Wyoming as described on the official
plat thereof.
-,
3. That by reason of the said conveyance, Max F. Jackman and Arlene J. Jackman
became the owners of the real property as joint tenants and title thereto vested in them continuously
from said date of conveyance as described in said Warranty Deed, until the date of death of Max
F. Jackman on October 24, 2004 at which time title to the above described real property vested
absolutely in Arlene F. Jackman in accordance with the provisions of §2-9-102, W.S. (1980).
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4. Affiant avers and certifies that deceased is the identical party named with Affiant in
the aforementioned deed whose death terminated his interest, title and estate in the said real
property; and Affiant attaches hereto and makes a part of this Affidavit a copy of the official
certificate of death of decedent, duly certified by the public authority in which said death certificate
is a matter of record.
Dated this ~í.2A~'Of November, 2005.
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C~~L"/ ,-~_2-/L"-./,f.7~(;-¿;!':J._.>,<¡.¿¿_/L._________~
//~/ Àì'lene)f: Jackman
(j!/ J.
State of Utah
County of 2.);,j~f ¿¿(it
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The foregoing instrument was subscribed and svvorn to me by Adene F. Jackman this (;
day of November, 2005.
Witness my hand and official seal.
My Commission Expires:
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() Notary yublic
NOTAr¿y PUBLIC
JERROLD LANCE CULP
1344 W"tlt 4ó75 South
00d"n, Uj"h O' '¡OO
My COWllii;¡;iol'1 E~ JjrilS
"O"I,,/;...r 15, 2008
S'fNI'EOF UTAH
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STATE OF UTAH - DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
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DECEDENT
STATE FilE IHIMßEH
FIRST, ,M,IDPLE, _ LASr- " [î"šEx,SEX--, - 3a OATEOfDEATH(Mo,[:¿q, fr) ,}3'bTiMË"ÕFlJfAHI(2,', J)(_c.'oCk)
~1ax Fredrick JACKNAN lIlI~e October 24, 2004 1128
-4 DATE OF BIRTH (1.10, Day, Yr.) 5. AG, E"."L, ,.,SI Bitth4~~tj~!R 1 '''!0,'R~I~ If l~t~DER 2~.HRS-_ 6,8, IR'iHPLA-C, E Tc;¡;;-¡'Slal,e or ForeiQn- COllntry)J7·SOCI".l SECURITYfiLJMm::-,R -
July 1, 1926 7~1 .:..~lMol1lns]-uai~ HoufJr.1Tnuté'k Brinton, Utah 529-28-6240
Ba, PLACE¡ HOSPITAL (~~,~~;tO,-, ~sp'laJa;;7TÄLl 6TIIER LOcATlõri"S:- ~- ---- ~- 8b -ÑN,\E.Of {·OS~ITA.l, t~-UHSING HOME OROTHERFACîUTy'~~~-------~--
OFOEATH [i ,'- ,', "', [0. ¡--v1 _, (!fouts/úe:afacilitY,Q/\lestieeladdressofloca/lon)
(check. only ¡ ......-J 1. Inpatient . ' , " 5. tlwslng Ho~e L..:'":.J o. ResIdence (any)
one) 02 ERiOulpal"nl 03D~0 7,Olh,,(sp<!afyJ 1778 East 6400 South
ikCiTY:TO~RLOCÁTíõ,¡ OF DEATH' - [So, CDUNTY OF DEATH . , ..._~ 9, SURVIVING, SPOUSE (if, ¡o¡jf~, g¡\I~ maiden name)
~llIrray L Salt Lake -..J Arlene Jones
10\~'š'DEcË6E¡:n 1~: MARITAL ~TATUS ~- 12a ,OECE[)EI~rS USUAL OCCUPATIOti(Gllt: ~j¡ld ;;r~~o(k oone ,¡liP-MID OFBUSltlEss"Of"iIïjnus ffr(-
~Yt~ ~gl/¿WC~~? 0 1. Ntlv~r MoJ¡riad 0 =3.. Widowed dunl19 most of \..orx"nglJfe. 00 UOTenlerrc:/¡(ed) Gran i te School
l31.Ye~ 0 2.rlQ ~2:M~iri~d 04 Divorœd Educator District
13a RESIDENCE ~ STREET AND rHJMBER Db cln TO"M -OR COMI,HJtÚIY·----[13; COUNn~- -- -¡13dSTATE -
1778 East 6400 South ['1uLray Sd1t Lake Utah
1~SIOE CiTY 13fZ1P CO~I'¡' " W~ """,",om",,,,,",,,", TF-'· 0 "" ['''''"" "';", """,' ~ Tî6Ei5LiCATIOH (speaf¡-;;;¡Y¡;igf1f:5I
LIMITS? (,1 yes, $peoty) - J¡¡d¡;'¡ll (lilba rn.,¡y Le únt£ ¡ed), g, ,d~ w.'Jplded) [Jomen!al)' or
r~ Japanests, ale: (Spaç¡f)) Secondar¡ (0-1:'.) College (13-16
LJÇ 1 Yes 84121 0 1 Mex.lcan 0 2 Cuban . ~ Of 1h) ")
o 2 No 0 3 Puerto Rican [J 4 Other (SpeClf'/) \'¡h l te ~ 1
17.FATHER.'S NAME (First. Middle, 1-95t) 16, f',1AJDEr W,ME OF t.10HtER. (Fils!, h/irJdle. L<Jsl) '---
Fcederick Charles Jackman Jessie l'iilhelIllina t-Iaxfield
PARENTS
INFORMANT
19, NM1E. RELA TlONSHIP AND MAILING ÄDDRESS OF It IFORMANT
Arlene Jackman (wife) 1778 East 6400 South, ~ILlrray, utah
84121
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20, I,IETHOO OF DISPOSITION
DISPOSITION
21a DArE OF DISPOSITION [21b PLACE OF DISPOSIlIOI~ (lIa1)/: ofcemt:/ery 21::: lOCATIOtl e,ti or 10·...11, Stata
t.:/'Umølory or oil ~ plate)
:~)4Bunal,~\~5cremal'onOr¡R.mo,"1 28,2004 ¡'Inrray city Cemetery Jlurray, ntah
22 slm~ WŒRAl SERVICE lIC~;~:: ~,Cann~)~rC~~S~;~~IBER -12~FU~RA'HOf.'E IlIa~:I:';~:~;~e~f or~l~~~_·_n
If nQ" t c.ertifi8," by med"...1 "ami"", was de.lh repon.d to ME? LJ 1. Yes ~,"" 124, 6U b. Bel,Jgal 131 vd.
" If~e5,£!f,t~rthedalaandtjúUrrbpOlted. S'l I 'l'c C'i 1 IT
I, ,E, CASE ND HR MD DAY YEAR ' at "d \ ., ly, ~
._~~~ ~... ."., '",,'., " uu .u=~~ --..,¡¡'1.1~.j----,
CERTIFIER
Lx! 1.' CERTIFYING PHYSI~IAN_ T.~ the, be~1 ,af my kno;/flüdga: death occufled allhe lime. dale. and placf:j. and due to the c.Juse(s) and marmer as stated
rJ 2_ MEDICA,l EXAMINER/LAW ENFORCE~lEtlT OFFI .~ On the basis of t;:,I(ami¡¡¡¡liGn and/or ir:'..e!itigdlion, in my opinion, death occurred at tha time. diJle, pl3œ and due (0 the
-- - causa(s) and'ñiãñne s ¡''fte~ - 7 /
270 SIG ATlJRE A;¡~T¡:t;?~ _ ~_,~ ! I{'Û ______ r~ ~c~E2M8~~~:s;¡-~T)d 7~\~~"2 (':~1:~;~~
28 NA.\1E AND AD RE SO PERSON Y'JliQ ¡FlED UIE CAUSE OF DEATH (Item 31) (Tj"{>e/PmJt)
Steven C. Horton, N,D. 324 East 10th Avenue, Salt Lake City, UT 84103
29, REGISTRAR'S SIG~'IAIURE ' ' '~' ., . 1;1 /..J - 30a, DATE REGISTRAR NOTIFIED OF DEATH ¡30b DATE FILED (Mo., Day, Yr.)
'., MtUC1.:U)l1 f."Y' (Afo, Day, Yr) October 27 2004
, ,
31. PART I ~~T~~~T~:~I~~~s;f:n~~~r~I~~.c~R ~~~~~~;~~~t'. f( 1:¡S;~t~~~ ;~~ g~~~~'O~OE~~¡~ ~{: ~EH fltE MODE OF 0 tll G. SUCH AS CARDIAC I ~~~~'~~~~~S/;I/:~~'
'Y5c.he rTilr, c; ~ dO~"4a.¡2" ii. u
, OUI;:TO,,(ORASACOtlSEQ~~C~OF): ( _ / ~
¿nr-Da..ti..:~J~.t.!<¡-Ú:>~ /1 <'--
, ','.," DUE TO (OR AS A COfISEC\UE"CE OF) !
REGISTRAR
IMMEPIA TE CAUSE (Final
disease or çonditíon resultmg
in defllh)
1 Dealh
[' ?'" .l~
I -- .L..L__
I)'~~
I~~- I
I
Sequentially list conditions, if
any, leading to immediate
cause, Enler UNDERLYING,
CA.USE (disease or injury thai
iniltated e....ents resultmg ill
dealh) LAST
c,
DUE TO (OR A,S A CONSEQUEtJCE OF)'
--~--~
,j,"
._~--~
CAUSE OF
DEA TI1
PART II Ol~er SIgnificant COnQlllOns con!IIDutlng \0 dealh 32 IH YOUR. OPINtml, TOBACCO USE IH r~E EJECE(JEtir --~JJ3a ~::JASAf¡AuroPS(-[3b V~RE;U10PSY ---
tJul nol resuHlng In \tIe undeJlymg caLJ~a 91Vt1n in Part I [- m..f':" PERFORMED? Flf D!NGS AVAilABLE
/) / j l . J 1 Prùbably cofltllbuted 10 the cause at deaHl L~:) NOU USER PRIOR 10 COMPl E lION
_ _~2--.Ll ~L~C r J_~~~ 02 W¡:¡slhtlunderl~lngcausao deüth Of CAUSE OF DEAll17
03 Old not contribute to U1e c...use of death 0 6 ~W~~ ~:IU D 1 Yes kJ 2 No [J 1 Y!òs 0 2 No
o 4 Is unkno....n In relation to the caU$e o( death
· =.35"-, -[)A1E OF HUURY (l.Ia_, Day, Yr.) 35b TIME OF INJURY 35c_ INJURY AT ~·.¡ORK7 '¡35d PLACE OF _lt~JURY _ AI home {ami st.;;¡ (ad~-¡Y--
'.,,;' - (24 Hour Clock) 0 1,Yes LJ2.r~o office,Öw!dIl1g.e{C,(~pe!;lfy)" ' ,
. _.__.~-------
35j),_lOCATION (S/fe-et or rural route number, city or lowo, county iJnd slale.) 35f If molor ...etudE! accid~nt sp(:lclfy it de¡:;edenl was dliver.
¡:;a~5engar or pedeslllan
34, MANNER OF DEATH
l~1. Natural