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Affidavit of Survivorship
I, George W. Mansfield, being of lawful age and duly sworn according to
law, upon my oath, depose and state:
That under the date of August 25, 1983, for valuable consideration,
William Lee Knopp, by deed of that date, which deed was duly filed of record in
the Office of the Lincoln County Clerk, on September 28, 1983, in Book 205 of
Photostatic Records on Page 467, conveyed to George W. Mansfield and/or
Catherine Mansfield, who were husband and wife, the following described
property to-wit:
Lot twenty-seven (27) in Star Valley Ranch Plat fourteen (14) as
platted and recorded in the official records of Lincoln County,
Wyoming
That by reason of said conveyance aforesaid, the said George W.
Mansfield and Catherine Mansfield became the owners of said real property, and
title thereto vested in them continuously from the date of said conveyance to the
date of death of Catherine Mansfield, also known as Catherine Estella Mansfield,
on the 27th day of November, 2001. That by reason of and upon the death of
Catherine Mansfield, title to the above described real property vested absolutely
in George W. Mansfield.
Affiant avers and certifies that Catherine Mansfield, is the identical party
named with George W. Mansfield in the aforementioned deed, whose death
terminated her interest, title and estate in said real property; and Affiant attaches
hereto and makes a part of this affidavit, a copy of the Official Certificate of Death
of said decedent, duly certified by the public authority in which said death
certificate is a matter of record.
Dated this 2- day of r101)
,2005.
[3
State of C~(/oJ L(). )
~D /7 /7. )ss.
County off.:j\rl(}f/{ Jti,XC )
Subscribed and sworn to before m~L-ª notary pub,liS in and for said County
and State, by George W. Mansfield, this ~ day of f !{)U. , 2005.
WITNESS my hand and official seal.
BOBBIE FERGUSON
Notary Public
state af Iddha
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My Commission EXPireqalì1
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RECEIVED 11/15/2005 at 2:56 PM
RECEIVING # 913717
BOOK: 604 PAGE: 789
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
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,.'i':'STATE OF IDAHO
.",.iDAHO DEPARTMENT OF HEALTH AND WELFARE
CENTER FOR VITAL STATISTICS AND HEALTH POLICY
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State of Idaho
CERTIFICATE OF DEATH
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Slale File No. __ ~
local Reg No 7iCJ---¿
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Catherine
~Al E Of DEATH 1',10111" Day, '~ilfJ
Female ,November 27, 2001
SOCIAL SECURITY NU'.\SER
BIRTtJP~ ",CE (C,ry is,,], :;';1111 Of "",e.g,' COunlryJ
518-22-]5]9
, Idaho Falls, Idaho
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WAS DECEDENT EVER rrl U S ARt.~ED
FORCES1
PLACE
OF DEATH
¡Cht!cll unly
0t1..} *
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(1) [)() Inpatienl
(2) 0 ERIOutpatient (3) 0 DOA
(4) 0 Long-Term Care Facility
(5) 0 Own Residence
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I,
(6) 0 Other Private Residence
(7) 0 Other ¡Specify)
o Ves !XJ ,.0
F:CIUTY r4AME AND ADDl(f5,S ,I¡~ ~UI;J i'QSp'lIJ/. "nler,..'1.~rnl ,ff pldCl, SIte,1 and 'wmöerJ
.. Eastern Idahú, Regi()nål Medical Center
CQUN TY Of' OF ATH
.
Idaho Falls Bonneville
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DECEDENT'S LJSU<\l OCCUPATION ¡GM:I *mc uI wOfM 0011' KltlO OF BUSINESS, INDuSTRY
dUfmg most at ",orAl"'} Me, Ou nOI u.. retlr.d.} ,
Sales Clerk
RESIDENCE STArE
STREET AND ~IUMBER
..., õ
m 3
Mk
0"
~;
~ :
z&
ZIP CODE
Idaho
INSIDE cln LIMITS?'
168 1/2 9th Street
,~ 83404
!5 DECEDErH 5 EDlJC,l.T!ON
(Spec'fy (JI'Ily hl(j""; ')fadø Ct;mplerftd)
mVes CNo
iXlNO
Utah
White
College (1·4 Of 5+)
ElemenlaryfSecondary (0-/2)
12
I I~ (Specify':
fATHER NAME
MOTHER FULL M"IDErl ~ AME
BIRTHPLACE
Noral 0 ¡ dell Brown
Utah
Edna May Christensen
INF<?nMAr~T'3 'lAME ¡TrPðlPnnr)
M....,Llrm ADDRESS i$11"f!11 3f'd II,JlntIfJr 01 Rur¡¡1 A(wtfl /JumDer. Co/I' or row", Slille, Z..p Cod!!)
~:;orge,¡1.Hans field
.168 1/2 9th Street, Idaho Falls, Idaho 8]404
METHOD OF P¡SPOSI~IO~
.
LOCATlOt CI!~ Of To...n, :jl.ale
Idaho Falls, Idaho
Falls, ID, 8]402
...
27 PART I" Enter the diseases, injuries,' or complications that caused the death. Do nol enter the mode 01 dYing, such as can.1lac or fesplralor¡ a"esl,
sh,OCk, O( heae1 lailure, Lis! only one cause on each line
'~" , ." IMMEDIATE CAUSE
IMMEDIATE :CA'uSE (Final
disease or condlrion ,"" ~ (ì¿;~~'¿A...'}J !?L.~"")/Y,-""1/~ Cl.-'".¥'~'-¡-
resulting in death) 'a. '" ~UE _ TO (0', a.s " COr1~eqtJer1ce 0/). ---->'. ",:",
b, ~}S/~ Z0 l1ná<Jhyy¿.";(¿.¿ 1J,.·{¿~£lt-é¿r9-tÜ'L/
~TO(O'as..con5tXllJ~r1çltof¡
,f}1¿.Þ.okctiè.- Ó7'zl--7A..~-r> CcU>i:!~--7'1.(/YVVC-<.....--'
DUE, TO" (0/ .It d COr1S~quøf1ce of)
Sequenfially lisl conditions,
j any. leading to immediate
cause Enter UNDERlnNG
CAUSE (disease or injury
that Initiated evenrs
resulting in death) LAST
1~~~~:I~ðl~sle~lerva
:and Oealh
I
I
I
I
I
I
I
I
t
I
: .«
I
I
WERE AUTOPSY n"lDINGS A'/AIlABlE
PRIOR TO CaMPlE TION OF CAUSe
OF OEATH1
27, PART II, Other Signilicanl Conditions con!nbu.~Lng 10 death but nOl resu!tlng in the undðrlYlOg causa given 10
Part I. . , , " I,
'I;',,';¡:,I
WAS A~j ,.s.UTOP$Y
PERrORI,4ED?
DYes
KJNo
oNo
oVes
::?}r7fR~ 7 ŒT~LQ-L
Falls, rD, 83404, 208-529-260]