HomeMy WebLinkAbout914466
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AFFIDAVIT OF SURVIVORSHIP
STATE OF IDAHO
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RECEIVED 12/15/2005 at 11 :09 AM
RECEIVING # 914466
BOOK: 607 PAGE: 518
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
COUNTY OF BONNEVILLE
I, ALLEN CHARLES JORGENSEN, being duly sworn under oath, state as follows:
1. That Kathleen Kay Jorgensen jointly held title with me to land in Lincoln County,
Wyoming, more particularly described as follows:
Lot Sixty-Six (66) in Star Valley Ranch Plat Ten (10) as platted and recorded in
the official records of Lincoln County, Wyoming.
1~
Attached hereto is a copy of the Warranty Deed that created that conveyed the title to the
property, recorded in the Lincoln County, Wyoming, land records in Book 289PR at Page 672
and 673, on September 20, 1990, as Instrument No. 723404.
2. That Kathleen Kay Jorgensen and I intended to hold, and did hold, title to the
propeliy as husband and wife even though that was not recited in our deed to the property.
3, That as her surviving spouse, I hereby certify that of Kathleen Kay Jorgensen died
on November 20, 1999. Attached hereto is an original copy of the Certificate of Death issued for
Kathleen Kay Jorgensen.
4, That pursuant to Wyoming Statutes §§ 2-9-102 and 34-11-101, I certify that the
tenancy of Kathleen Kay Jorgensen in the above property has been terminated by her death, and
that title to the above-referenced land is now solely in the name of Allen Charles Jorgensen, a
single man.
DATED this L day of December, 2005.
:1), ij)...Q/y
~ ENSEN
ACKNOWLEDGED, SUBSCRIBED AND SWORN,,~nl,bÿfore me by ALLEN
CHARLES JORGENSEN this ~ day of December, 200?:;:::'L'£(",,~',iS;",/~;:i;:<::\
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'VITNESS my hand and official seal. (76 j,~J,~/5,. /,(', \}j" ", (J,!t,:) ..
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'{Commission expires:
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Bremer ton
Allen Jorgensen
518-86-6511
17 DECEDENT'S EOUCATlQN
($pecity only I~iç;¡na!i! Qrada ccmph:Had)
C.Jliaça (1·4 cr 5+)
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14 MARITAL STATUS---Married,
Never Married. Widowed.
O¡'/orcad (Specify)
lS SURVIVING SPquSE (l wile. give-malden, nama)
emale 11/20/99
7 'SIRTH'o,À.TE(MO. Dq,y YÚ 8·'~¡ATHPLÄ.ÇE,.,;' '/ : g.Y/AS DECE:OENT EVE,R 'l"o CO~rHY OF DEATH
. (City, Stale or Foráign CQl,Jhtry) IN U,S. ARMED FORCES? , , "
Òl/19/59 IdahQ F¡¡.lls,:J;daho (Yes/No) No ¡"itsar)
12 PLACE OF DEATfi-.,1il BOx FOR PLACE TfiEN GIvE ADDRESS, OR INSTITWTlON NAME !¡3 SMOKING IN LAST
'1,=HOM£,2CINTRAtiSPOfn XXWffiGRM/OUTPTN 4='HOSP SC: NURtiOME 6COllifAPLACE 15YEARS?(Yssl~JO)
Harrison ~ emorial lios ital Yes
16 SOCIAL SECURITY NO
James AlbeJ;'t Sha\\TVeJ;'
30 INFORMANT-NAME
31 MAILING ADDRE?S
1095 Mojave
Shidey Thomas
STREET OR RFD NO
CITY DR TOWN
STATE
ZIP
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(Yes / No) Specify.
No
27 ZIP CODE
Finänci$l Advisor
18' USUAL OCCÚPA TION (Giv& kind o(w,?rk d9ne
dunf1.ç.¡ most 01, working lite:, DO NOT USE AET A~D)
19 ,KIND OF BUSINESS OR INDUSTRY
Financial
20. v"¡as DaCE/oent of Hispdnic ollgln cr aescef1.(? (Anceslry) (Specit'¡
Yas or No I' Yes. spec¡f-y Cuban. Mexican, Puerto Rican, etc.)
1095 Hojave
Idaho· Falls
24 INSIDE CITY 25A CÒUNTY
LIMITS?
(Yeli I No)
Yeg
258 LENGTH OF 26 STATE
I RES. IN CO,
140 Yrs
ID
I 83¿.O¿t
22. RESIDENCE-NWMaER AND STREET
23. CITYfTOWN, OR LOCATION
Bonneville
28. FATHER'S NAME-:-FIRST, MIDDLE. LAST
29. Mo.TH~A'S NAfr1E--:-FIRST, MIDDLE. MAIDEN SUMNAME
Idal10 Falls,
ID
83404
35 LOCATlON-{;ITYfTOWN, STATE
Grove City Crematory
Blackfoot,
38 ADDRESS OF FACILITY
Hay
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lA
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Funeral Chapel
Bremerton,
Idaho
53()3 Kitsap
HA 98312
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TO THE B¡;ST OF MY KNOWLEDaE, DEATfi OCtUBRED AT TfiE T'ME DATE AND PLACE
AND WAS QUE TO Tfi~ CAUSE(S) STATED
TO BE COMPLETEQ ONL Y BY IoUDtCAL axA jI"~H OH COHo"aH
43 OJ'j THE 8ASIS OF EXAMINATION AND/OR INVESTIGATiCN, IN MY CPINION DE.;TH OCCURRED AT
¡fiE TIME, DATE AND PLACE AN WAS DUE TO HiE CAUSE(S) STATED
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48 t-IAME ANO ADDR~SS OF CERTlFIER-PHYSICIÀN" M~DIC",L EXAMIN~R OR CORONER (Typ. qr Print)
Don Ursery, Cheif Deputy çoroner,614 Division
50 ENTER THE DISEASES. INJURIES, ORCOMPLIC.A,TIONS WHICH CÀUSED THE DEATH:
46 PRONOUNCED DE~D (Mo.. Day, Yf)
11/20/99
47 HOlJR PRONOUtjCEO DEAD
(24 firs b815
i 49 MEiCORONER FILE NUMBER
I
Port Orchard, HA98366 ~1l¿f4399
A,
Åc~te Dr~g Intpxication
Ave,
IMMEDIATE CAUSE (Final disease or
condilion resulting in de.III),
(Fl lJ,oxetine)
INTERVAL 8ETYiEEN ONSET AND
DEATfi
J
¡INTERVAL 8En\'EEN ONSET AND
DEATH
IIt'HER'VAL aEnVEEN ONSET Af'1O
I DEATH
INTERVAL BETWEEN ONSET AND
DEATfi
\;Si
.···'.·~I~
~~t:
\\
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d
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DO NOT ENTER THE MODE OF
DYING, SUCH AS CARDIAC QR
RESPIRATORY ARREST, SHOCK, OR B
HEART FAilURE LIST ONl Y ONE
CAUSE ON EACH LINE, . .. .
Sequ~nlially list conditiohs, if any,
leading 19 immediate CJus., Enler
UNDERl YING CAUSE (Diseas. or
Injury whic.h initialed ~Yenls lesulling .
in dealh) LAST,
OTHER SIGNIFICANT ëONDITiONS-'-cONDITIONS CONTRIBUTlN? TO DEÄTH BUT NOT RESULTING IN TfiE UNDERLYING CAUSE GIVEN ABOVE.
çhro¡Ü<:: Alcoholism w/fatty liver
52 AUTOPSY?
(Ya;¡/No)
Yes
WAS CASE REFERRED TO
t.1EOICAL EXAMINER OR
CCRONER? (YbS / NO)
Yes
ACC, ~UICIDE, HOM, UNDET"
OR PENDING INVEST (Spocify)
5S I.NJWRY qATE (Mo Day, y¡)
Accident
WA 98310