HomeMy WebLinkAbout913790
c n:::L55
Affidavit of Survivorship
I, Mary E. Roberts, being, of lawful age and duly sworn according to law,
upon my oath, depose and state:
That under the date of September 23, 1983, for valuable consideration,
James G. Roberts, by deed of that date, which deed was duly filed of record in
the Office of the Lincoln County Clerk, on September 23, 1983, in Book 205 of
Photostatic Records on Page 427, conveyed to James G. Roberts and Mary E.
Roberts, husband and wife, as tenants by the entireties with right of survivorship,
the following described property to-wit:
The Lot Numbered Nine (9) of the Block Numbered Twenty-Two
(22) of the First Addition to the Town of Kemmerer, County of
Lincoln, State of Wyoming
That by reason of said conveyance aforesaid, the said James G. Roberts
and Mary E. Roberts 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 James G. Roberts, also known as James Gordon Roberts, on the 27th
day of November, 2003. That by reason of and upon the death of James G.
Roberts, title to the above described real property vested absolutely in Mary E.
Roberts.
:!/û
Affiant avers and certifies that James G. Roberts, is the identical party
named with Mary E. Roberts in the aforementioned deed, whose death
terminated his 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 /! day of 7/D-t.v~-:-,.v{,,,,u.005.
RECEIVED 11/17/2005 at 2:10 PM
RECEIVING # 913790
BOOK: 605 PAGE: 155
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
'J1(t~/, (~ a~¿-Þ-V
{I Mary E. Roberts
State of W!)tý1, ;'(1&1
County of L (~f\ cdl 11
)
)ss.
)
Subscribed and sworn to before me, a notary public in and for said County
and State, by Mary E. Roberts, this /l day of (VOU-¿ yvd:ur- , 2005.
WITNESS my hand and official seal.
GAY NELL PICKlNPAUGH - NOTARY PUBLIC
COUNTY OF STATE OF
UNCOLN \WOMING
MY COMMISSION EXPIRES MARCH 19. 2008
~u~
ublic
My Commission Expires: (Y1CJr·ch Ii dðû1J
I
ThIS docmnðnt is bainu tt-:t;ürdm1
by Rocky h.ijountüìn TitlG InSIJl"iinCI8
ÂQlmcy of Uncolilî Cotmiy Plf; 8
C;OIUilt(.i:0V Olil~f
~~
~t
~~
!y~}
.'J'-
:;~ltéf;
~ff~
~.'" .
~
Ij
"'~";'I'
.;..,-c",
:( ,[¡i; ,
wl~!
r.~~
\:'....}5
~:~~~ .
·~%r·J. .
':'ri£.I' .
,.;'~~i': '
~f' .
"'.':::"
~,
,...,~
~.%.J.~.t.~ ..~
¡:E[f
,~;..,~
~~r{~
:: .:.:.:..
I
~~:~~.
@J
[;;';'1'
¡W;.
..~.".
:; ';.~~,
~: .:...~
~. ,-,-:"'::!
~k~~
t\t;ª .
~~~
¡j:::~
i:!.~J
'~'í'~~i:J
~ .~.~."..
f(¡
¡~¡
if;!'
,.",,"',1;,
~j
~~
~~J.u1,i.~~~4.:i~~¡, j).;{á~ifflj~ÆQ¡jJW"¡:4.;i:i#-,:~,;";;'~I:':":¡jí¡¡J:4it¡"Á¡';,;:.q ' '0'4..iJjt;r~H_¡'
$TATE OF UTAH - DEPARTMENT OF HEALTH
CERTIFICA TE OF DEATH
18- 5410 ST Ar~ FIL E tllIl.1BER
. 1, NAME OF DECEDENT fiRST LAST ], SEX Ja DATE OF DEATH (Aio" Oar. ~'r) JtJ TIM!:. or DEATli (2-1 fir citxk¡
I' ,~1 ':l,:<':"'~!' .', ", ' . ,
'_'¿~<ifn~~_~_~Qrdo'l~__---c-,,-~O~~rrr_S. ale L~vembe'~27 200l. _L~~__
'. . DATE DF 8mH (MP. 0",. Yr) .. .... ..1 SAGE'.,L." B"'hd'Yl';ò~::;'.'[R ';.';ff~;~l ~:;~~:. 6 BIRTHPLACE (C,ry. 5''''0' FO"'Qo Co"nlo') I' SOCIAL SECUf<lTY 11lJ/.,8ER
-_-HªHÌLZZ..-.l22.L . Ilg~_.C_. FrO!lt:ierLHYQmiIlg~_2.º-::2L,=~1.41._
'.'.p. LAC. EI HaS P.'..TAL. (I."'" ,COO.' ...... HO.JP4.... .."'.'.".)....... AL..l QTHER .LOCAT.IONS: . Bb NAI,'EOF HOS~I1Al, NURSING HOME OR OTHER FACILITY
OFOEATH 'fVl" ......... .... -..,.' .,..... I ~J:' '. D. (¡[ati!s!dð äfaÔhly, fJI'It1S!(t!eladdless.oflocafIDn)
(ctleck only ¡ ~. 1 Inpa!lent ' . .', .' . l 5 UUfslng HGme ,6, RI; ~ldélnce (any) '. .
on.) r'2ERJOulp.Ji,nl 03DOA ID(o,,,,,(,p.e;fYJ University Hospital
~;.;..:.:-",--,.;;...-:..L~.____-:-~~_~ ...,..". .."-- ~'''-------~--~__~~._ "7". . . .
". CITY.. TO.,.WN. OR LDCA1I0N ¡)F PEA. ~t.'... ." ...:>..,...... 'd. COUNTY PF DEATH 9 SU.RVIV. JNG SP.OUSE (;f ''''e, O"a m"d.n n,m,)
Salt Lake City¡<' ." Salt Lake Nary Ellen Peterson
la'--WAS õecEoEÑr- 11. ,...~ARITAL STATUS,",- 12;DEcEOENT'S USLJ~L OCCUPATIOt~ (Gn't! f:Jnd cf.\~o~/( dOntJ 12b KING OF 8UW:ESSO~iîlJSTRy-~~-
~~~~g'/¿WC~§7 iD \_ tj~v~r,M~rriad. 0, 3" Wido....ed dUlllJQ most 01 worAIIJÇJ Me. Do/lOT ell/ai' fell/ad)
I:;] 'Ye, [J 2. Na !G:]2. M.ni.d 0.4 D;,'orc,d Produce Nanager
1); AESIDENŒS1REET AND NUt.1Sffi-- -r~ CITY 10\''.1/ OR COMMUNITY
313 Ruby Street _L Kelmnerer
lliItiSlDECiïY'I13fifPC~DE 14 -;N"S OECË6E-'/T OF HISPANIC ûFtIGJN? 01 yss GJ 2 No 15 f{ð"CE Bldd'., V,.t.ile, Am
lIMlfS? (If yes Specdy) JU Indian (tr,be mB ' bu tln1ered)
Japanese etc (Specify)
Ii: 1 Yu 0 1 MSJocan 0 2 Cllban
C 2 tlo I 83101 I[J 3Pu'rtoRicon 0 4.0&"r(Sp"ify)
Grocery
13c, COUUTY
Lincoln
13d, STATE
\Jyollling
\6 EDlICATIOiJ (~peC~f}; O~¡;:tl;g-¡;;;¡
çlade COnlµfe/ðä) Eltrmcntaryor
Secondarf (0-12) CGII"ge (13-16
or 1Jt.)
PARENTS
1], FATHER'S J~AJ.1E {Fils!, MickJle,
Hugh Roberts
Hhite
12
18 MAJDEtJ NM'E OF MOTHER (First, Afield/a, last)
Nary Kulinsky
INFORMANT
19 tjN.iE. RELA110NSHJP AND MAILING ADDRESS QF INfORMANT
Nary Ellen Roberts, Wife, 313 Ruby Street Kemmerer, Hyoming 83101
20, METHOD OF DISPOSITION
DISPOSITION [1b PLACE OF DISPOSIT!otl (nama of ct!lI1elery 21c lOCA110r~ _ CII ' 0110"[1 State
crematory or olnar place)
12-02-2003 KeIllI11erer Cemetery Kemmerer, llyoming
l]ì.~~~~~ IJ"BER' 124¿1~:En~~~;1E ;~~8e ~n:~d;;;;VOme -~--S '-
1 5 ~ast Center treet
:~ DATE DE ASEO WAS LA.ST. 126.., If nOlCe. r1. jfifHj.b~ medi.ca.! e:tamlnt:f, was death repollt.lu 10 M,E,? D 1. Yes n 2 No K - U. 1 B 4 03 6
AT ¡ END~ BY CER flFYlr~G PHYSICIAN ... II yeS,enler !l'ledal8 and hour fllporlad, LA amas , t a 1
~ov~be~_ 27 20 . IMECI\SENO' .. HR MO DAY YEAR
270 CERTIFIER :,,: :¡:':;;',::...: .... .. ,
~ To lhe·;~SI:O;f~~ ·~c~;edge, dealt', occurred at the time, dale, and place, and due to Ihlil c.au~e(s) and manner as :slaled
DISPOSITION ,Ð 4 Bwiat
REGISTRAR
CERTIFIER [J
00 the;! t...sis of examination and/or invesl¡galion, in my opinion, death occurred al the lime. dale, place and due 10 the
o North Medical Drive Salt Lake Cit Utah 84132
130a. DATE REGISTRAR tlOTIFIEO OF DEATH ¡30b. 04.TE FILED ¡Me" Day, Yr.)
(Mo, Day, ~'(.)
December 02 2003
S,'OR COMPLICATIONS THAT CAUSED THE DEATH DO rWT ElnER THE MODE OF DYIUG, SUCH AS CARDIAC I ApproÚmate In/en/a!
t1QCI\P~;H~RT fAILURE, LIST ONLY Ot~E CAUSE atl EACH LINE, I Be/ween Onset and
IMMEDIATE CAUSE (Fino)
disease or condilion resulting
ill death)
. fe' P:rA..A-r:rø..J
- . .... DUE TO (OR AS A COUSEOUEUCE OF);
b. Se ('tU'{...{
"'--'. . DUE.TO (OR AS A COI.sEQUEUCE OF);
"'::> Tl.IW\L 'L-
pû~ TO (OR AS A COI!SEQUEUCE OF)'
i °r:t.
-·k-
.--~- \ ^'::'..Y_
I
...J.__L,,:/ _':.'=------
Sequentially list conditions, it
any. leading 10 immediate
C¡¡US2 Enter lJNDERL YING
CAUSE (disea~¿ or injury Ih~t
Inillaled events tesLJltmg In
deatt\) LAST
d.
CAUSE OF
DEAnt
-- . .. .' . ...- ---------------I--~-----_·- -------------
P ART II 0111..". ~.g(l .rlcant C 00dillo.n.s co '."'.ib.. ,.'11"." '.,.....d e¡;¡t!1 32 JU YOUR OPINIOtl 1 aBACCO USE BY TIlE DECEOEt r 33.:1 VIAS AN AU rops'! [331) \'VERE AUTOPSY
bl.JI no! result((]g In Il1ö uncJady!ng causa gl~an Inf'an¡ 0 [~ PERrORt.\EDí' FIIIOINGS AVAilABLE
1 Probably conlflbulad to Ihl! cause of death y,5 NOlI USER I PHIO[{ TO COtIPlETION
~-- --~- 02 VI<lsU,eunderIYln¡¡ç¿¡tJhlofdealh I OF CAUSE 0,.. OEl>.l/P
[J 3 Old not cO¡llrlbutú to Ihb cause of dealh 0 6 ~: ~~J~i:i'VH [J 1 Yes LZ¡ 2 tJo I [J 1 '("5 l-J 2 No
~__ ... . ... =.11] 4 Is ur.known In ¡ol<lIIOrt to tile causa (Jf dtl~th
i1..,AtjNER OFDEATii-. '.. .- 3S'--.O.ATE.. 0. F.'.'.!..JURY (AID. o.r:v;¡. f3sì..35b TIME OF.. 1 :;¡iRYl'^:c HUe,", AT WORK7-.J 3SdPlACE O.FIì J!JR. Y--:..~I';;n.., fiJ~-;-lr~,-'~;;fY.--
- . ., .'. L.. 124HO",CIOCA)J.9 1Y., [J2"" Q~>c..b""U,no."c (,p""')
~ ""0<.' 0 2 Ace,d'''l 35, LOÇATION (51..., or ,",,, ,"v" ;w~;¡;;;·. clry ~I ":;:;;~u~"Y .;;;ï"". J~ 135"/;;;;;;;;;-;'¡;;;:k-'~¡d"" ,p;C¡¡:; iid-';-,,,,,;:,-,-;,, d,;;;;:-
-:.~ 3 suie'd'. 0 4. Homicod, .. . -L p''''"O'' m p.d""""
..is ~~~:::,;"n.dO 6. ~:,~~:~.".n 350 OES,RIBJõ NOV/It/JURY OCCUf.RED (.n'" sequonce pi ,,·.n', which """ad '" injury.r¡¡¡¡mE OF 1N.f RY ",ould be enlmd m ',;;;;J,¡---.
PurpOSP.I)' or
AccidtlnLly
UDH·BVR
Fonn 12,
Rev, 1mB
'æ
"-
92-
I[)
'"
if)
I
a:
>
m
±
o
if)
This is to' certify that this is a true copyoUheç:;ertificate on file in this office. This cerlified copy is issued
under authority of section 26-2-22 of the Utah Code Annotated, 1953 As Amended.
Date Issued: December
2003
/3~) ¿ 1£ð~(f¿~
Barry E. Nangle
15,
County
SALT LAKE
Lc,~tI~rtr~a 1111/1//1111111111111/1111/111111111 11/1111111111