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000223
When Recorded, Mail to:
Mail Tax Statements to:
BRAD JERBIC;, Co-Trustee
7040 Obannon Drive
Las Vegas, Nevada 89117-2124
RECEIVED 8/14/2006 at 4:37 PM
RECEIVING # 921274
BOOK: 630 PAGE: 223
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SUCCESSOR CO-TRUSTEES
STATE OF NEVADA
ss:
COUNTY OF CLARK
We, BRAD JERBIC and BARBARA MEYER, being first duly sworn,
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depose and ~ay:
1. T~àt ALICE V. GOFFSTEIN created the ALICE V. GOFFSTEIN
TRUST, dated June 5, 1975 and was designated as the original
Trustee.
this
certificate
q::
¡
and accept the Trusteeship of
the ALICE V.
2. That ALICE V. GOFFSTEIN died on July 18, 2005, as
evidenced b~¡.the certified death certificate attached here~o.
3. That BRAD JERBIC and BARBARA MEYER are named in said
,I,:
Trust as the Successor Co-Trustees of the Trust; and hereby file
- '
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GOFFSTEIN T~UST, dated June 5, 1975.
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4. That there is real property owned by the ALICE V.
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GOFFSTEIN TRUST located in the County of Lincoln, State of Wyoming
which is leH~lly described as follows:
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This document is being recorded
by Rocky Mountain Title Insurance
Agency of Lincoln County as a
Courtesy Only
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000224
STAR VALLEY RANCH RV PARK PLAT 1 LOT 370 as platted and
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record~d in the Official Records of Lincoln County,
Wyoming.
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RESERVING THEREFROM all rights, title and interest in:
and to ~ny and all rights appertaining thereto.
Subject to all declarations of covenants, conditions
and reètrictions of record.
,
DATED \;his ¡q1fl'day of C'kf
, 2006.
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STATE OF NEVADA )
) ss:
COUNTY OF CLARK )
On this'~¡l~ay of ~ , 2006, before me, a Notary Public,
BRAD JERBIC;. who aCknoWl~~ed Uto me that he executed the above
~i
instrument, as the Successor Co-Trustee of ALICE TRUST,
dated June 5~ 1975.
"
NOTÃRY PUBLIC
STATE OF NEVADA
County 01 Clark
DEBRA A. MANN
Appl. No. 98-4200-1
. E inK ~8b. 4 2OtO
STATE OF OHIÒ!; )
~ ) ss:
COUNTY OF (ò¡jtu.£ )
On this,'rt day of ®ty , 2006, before me, a Notary Public,
BARBARA MEYER, who acknowledged to me that she executed the above
instrument, ~s the Successor Co-Trustee of ALICE V. GOFFSTEIN TRUST,
5~; 1975.
8T ÞOJ:;Y A. HENRY
, PublIc. SWe Qf Ohio
~ Expires
, April 21. 2010
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TYPE
OR PRINT
IN
PERMANENT
BLACK INK
fOEATH
OCCURRED IN
mTITUTI<JI
S!:E HANOOOO<
REGAIIDING
COMPlETION (Jf
RESIDENCE ITEMS
. . .
CONDITIONS
IF ANY
WHICH GAVE
RISE TO
IMMEDIATE
CAUSE
STATING THE
UNDERLYING
CAUSE LAST
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STATE OF NEVADA - DEPARTMENT OF HUMAN RESOURCES
DIVISION OF HEALTH - SECTION OF VITAL STATISTICS
I CERTIFICATE OF DEATH I
I
000225
LOCAL FilE NUMBER
DECEASED-NAME First
DATE OF DEATH (Monlh, Day, Year)
STATE FILE NUMBER
COUNTY OF DEATH
Middle
Last
1, Alice
CITY, TOWN OR LOCATION OF DEATH
GOF'FSTEIN
Clark
SEX
3b, Henderson
RACE-{e,g" White, Black, American
Indian. etc,) (Speclly)
5, Whi te
STATE OF BIRTH
(If not U,S,A" name country)
9a, Ohio
SOCIAL SECURITY NUMBER
CITIZEN OF WHAT COUN· D,ecedent's Education,
TRY grade completed,
9b, IJ. S. A. 10. 9
USUAL OCCUPATION (Give KInd 01 Work Done During Most of
Working Ule, Even If ReUred)
14a, Homemaker
CITY, TOWN, OR LOCATION
INSIDE CITY LIMITS
(Specify Yes or No)
15e, Yes
Last
~
13, 13'7-14-9669
RESIDENCE-STATE COUNTY
Own Home
STREET AND NUMBER
15a, Nevada 15b,
FATHER-NAME Arst
Clark
Middle
15c,
2436 Hi¡¡h Vi8~a Cr,
First Middle
Last
MAIDEN NAME
16, Edmund
INFORMANT-NAME (Type or Print)
Wood
'fa lor
(Street or RF,D, No" City or Town, State, Zip)
1k Michele Teriano - Dauahter 1. 1128 Hidden Mist Street Henderson Nevada 89052
BURIAL, CREMATION, REMOVAL, OTHER (Specify) CEMETERY OR CREMATORY-NAME LOCATION City or Town State
..
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19c, Las Ve as Nevada
Pal. Kortuary - Eastern .
rn A e 9 Ye 9 y a 89123
22a, On the basis of examination and/or Investigation, In my opinion death occurred
at Ihe time, dale and place and due to the cause(s) and manner slated,
(Signature and Title) ~
DATE SIGNED (Mo" Day, Yr,) HOUR OF DEATH
22b,
PRONOUNCED DEAD (Mo,! Day, Yr,)
22c.
PRONOUNCED DEAD (Hour)
21d, 22d, ON 22o, AT
NAME AND ADDRESS OF CERTIFIER (PHYSICIAN. A TTENOING PHYSICIAN, MEDICAL EXAMINER, OR CORONER), (Type or Print) LlCENS~U~BER
Eastern Ave. Las Vegas NV89123 23b, 7t/ r
DEATH DUE TO COMMU.NIC"....DISEASE
24c, YESD NOö"
REGISTRAR
DATE RECEIVED BY REGISTRAR (Mo" Day, Yr,)
fJ L 2 ~ 2005
Interval between onset and death
PART
I
(a
Interval between onset and death
! (b
Interval between onset and death
PART
II
c)
OTHER SIGNIFICANT CONDITIONS-Condlllons contributing 10 dealh but not resulting In the underlying cause given In Psrt 1,
. '
DATE OF INJURY (Mo" O.y, Yr,) HOUR OF INJURY
DESCRIBE HOW INJURY OCCURRED
ACC" SUICIDE, HOM.. UNDET,.
OR PENDING INVEST,
þs¡.~cify)
INJURY AT WORK
(Specify Yes or No)
288.
28b, 28c,
PLACE OF INJURY-At home, farm, streel, faclory, oHlce
building, etc, (Specify)
M 28d,
LocATION.
STREET OR R.F,D, No,
CITY OR TOWN
STATE
281,
28g,
STATE REGISTRAR
No. 292 430
"CERTIFIED TO BE A TRUE AND CORRECT COpy OF THE DOCUMENT ON FILE WITH THE REGISTRAR OF
VITAL STATISTICS, STATE OF NEVADA." This copy was issued by the Clark County Health District from State
certified documents as authorized by the State Board of Health pursuant to NRS 440.175.
NOT VALID
RAISED
COUNTY
y
::-
WITHOUT THE
SEAL OF THE CLARK
HEALTH DISTRICT
DONALD S, KWALICK, MD, M.P.H.
~:g;;r V;tal Stali,""
-,
Date Issued:
JUL 2 5 2005
CLARK COUNTY HEALTH DISTRICT
625 Shadow Lane P.O. Box 3902
Las Vegas, Nevada 89127
702-383-1223
Tax ID#~:~:~:¡:8) 51573
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