HomeMy WebLinkAbout925248
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. Affidavit of Survivor8hi~
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State of <b~ðming )
l3ttnr~aJ SS.
County of LlncelR )-
Sf 000080
BETTY COLLEEN KING, being first duly sworn upon HER oath, deposes and states as follows;
1.0" ttie 20TH OF OCTOBER 1996, my HUSBAND, LARRY G. KING passed away, as is evidenced
by the official certificate of death attached hereto and incorporated herein by this reference.
2, At the time of death my husband Jointly owned certain real property with me, said real property being
located in the County of Lincoln, State of Wyoming, and more particularly described as follows:
ALL OF LOT SEVEN (7), LOT EIGHT (8), LOT NINE (9), LOT TEN (10) AND LOT ELEVEN (11) IN BLOCK
SIX (6) OF THE HEUETT ADDITION TO THE TOWN OF COKEVILLE, ALL IN TRACT NUMBERED
EIGHTY-TWO (82), LINCOLN COUNTY, WYOMING AS SURVEYED, PLATTED AND RECORDED.
ALSO LOT TWELVE (12) IN BLOCK SIX (6) IN TRACT EIGHTY..TWO (82) OF THE HEUETT ADDITION TO
THE TOWN OF COKEVILLE, LINCOLN COUNTY, WYOMING
EXCEPTING OUT:
BEGINNING AT THE SOUTHEAST CORNER OF BLOCK SIX (6) RUNNING WEST ALONG STREET
NUMBER SEVEN (7), FOR TWENTY-ONE (21) FEET; STARTING AT THE SOUTHEAST CORNER OF
BLOCK SIX (6) AND RUNNING NORTH ALONG SAGE STREET FOR FORTY (40) FEET, THEN ON A
DIAGONAL LINE FROM THESE TWO POINTS WHICH IS A LINE OF FORTY-FIVE (45) FEET.
3. Said real property was originally conveyed to LARRY G, KING OR BETTY COLLEEN KING,
HUSBAND AND WIFE, by ALMA R. WALTON OR ,EMMA WALTON, HUSBAND AND WIFE, dated JULY 22,
1974, and recorded in the office of the LINCOLN County Clerk and Ex-Officio Register of D.eeds on
NOVEMBER 22, 1978, in Book 151 PR at Page 43. ,
4. By reaSQn of LARRY G. KING'. death, I am entitled to sole ownership of the above-mentioned real
property.' ,
Dated this \ -¿'" I - ~
~ C1ttu~
BETTY C L EN KING . :, Ô
Subscribed and Sworn to and acknowledged before me this
BETTY COLLEEN KING.
12.- I'O~
, by
Witness my hand and official seal,
. +
SHEILA GARRETT ¡
NOTARY ¡JU8L1C
STATE OF IDAHO
·+¥~H1ftlftf1f1!1f Jf.-"'tf'l'1J'1I; ßI!fIfl'+
RECEIVED 12/12/2006 at 2:13 PM
RECEIVING # 925248
BOOK: 643 PAGE: 80
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
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Ihl, Iorm I!; JIfnIIH under
IhIt VII.' S,....IQ Act
.rwt"tH,
SALT LAKE COY - COU!·U,.I HEAL1H DEPARlMENT
DIVISION OF VITAL STA 11STICS
~'
. ,
LOCAL FILE NUMBER
" NAME OF DECEDENT
18-4279
STATE OF UTAH· DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
000081
FIRST
MIDDLE
LAST
STATE FILE NUMBER
3a, DATE OF DEATH (1.10, Day, Yr,
October 20, 199 1~'30
7, SOCIAL SE URITY NUMBE
520-44-1932
LARRY
4. DATE OF BIRTH IAlo. Day. Y,,)
Feb. 25, 1943
HOSPITAL:
lX " In ali8nt 0 2, ER10uIøalienl 0 3. DOA
&c. CITY, TOWN OR LOCATION OF DEATH
OTHER:
05. Nursln Home 06. Residence 07, Other
8d. COUNTY OF DEATH
8b, NAME OF HOSPITAL, NURSING HOME OR OTHER FACILITY (/I ou/sit16 a racility,
(live .".elllddt." tif bca/ion)
University HQspital
to
!KI2. Married
o 4. Divorced
Salt Lake
12a. DECEDENTS USUAL OCCUPATION (Give kInd 01 W""' done
dUring mosl of working Hie. Do NOT use 'etlfed) ,
9. SURVIVING SPOUSE (H Mle.{li.,. "..iden ".",.)
Colleen Walton
DECEDENT
Salt L:!ke
10, WAS DECEDENT
EVER IN THE U.S.
ARMED FORCES
I8II.Ve.D2,No Davldowed
13an'WE~~ðST~¡ET :ND NUMBER
P.O. Box 2~1
13e, INSIDE CITY 131. ZIP CODE
LIMITS?
C it Utah
11. MARITAL STATUS
o 1. Nevi' Merried
12b, KIND OF BUSINESS OR INDUSTRY
Mechanic
Coal
Mining
13b, CITY, TOWN OR COMMUNITY
Cokeville
13c. COUNTY
Lincoln
13d, STATE
Wyoming
181,. Ya. D2.No
83114
14, WAS DECEDENT OF HISPANIC ORIGIN? 0 101 15. RACE, Black, While, Am. IndIan
fif yes. Spedly) 1. Vel ~ 2, No (Tribe may"" ent.red). Japanese,
etc:, (SpecIfy) Wh i t e
o t. Mexican 02, Cube" 0 3,Puerto Rlan D., OIher (Søectfy)
16. EDUCATION (Specify only highe51 grade
comple,ed) Elementary or Secondary
10,12) College (13,16 or 17 +) 12
PARENTS
17. FATHER'S NAME (Firs!. Middle. LaSI)
John Calenzo
King
18, MAIDEN NAME OF MOTHER (Firsl, Middl.. Lasl)
Marguerette Johanna
Busskohl
19, NAME, RELATIONSHIP AND MAILING ADDRESS OF INFORMANT
INFORMANT WIFE - Colleen W. King 17th and Sage, P.O. Box 201 I Cokevi11e, Wyoming 83114
DlsposmON
21a. DATE OF DISPOSITION
Zlb. PLACE OF DISPOSITION tName 01
cemelely. cr.matof)', Of olher plac.)
21C. LOCATION, City or Town. Stale
CERTIFIER
~
E DECEASED WAS LAST
A NDED BY CERTIFYING PHYSICIAN
0ctnber 20 19Q6
27a. CERTIFIER
U 1, CE'RTIFYING PHYSICIAN To the best of my knowledge. death occurred al the time. dale. and pllee. and due '0 Ihe CBUS8(S) Ind mlnner 8S slaled,
o 2, MEDICAL EXAMINER /lAW ENFORCEMENT OFFICIAL On the buls 01 uemlnltlon and/o' Invlatlgatlon, In my opinion, d..th occurred II the time.
dale, pllce, Ind due 10 Ihe caua.ls) Ind manner as slated,
27b, SIGNATURE AND TITLE OF CERTIFIER
J~ J WOAd I Mr')
Lincoln County
Oct. 24, 1996 Cokeville Cemetery Cokeville, Wyoming
23. LICENSEE NUMBER 24, FUNERAL HOME IName. _elS and Meen.. number)
22-112140 ~l;~~g9g~rt.for: Matthews Mortuary
26. II nolcenllied by rnadteal..am,ner. Wuo.... reponed ID M.E,¡ 702 Clay S tree t
"yM, enter the dalund hour ,.-ed: M.E. Ca..No, Montpelier, Idaho
HOUR MQ, DAY
83254
27c. LICENSE NUMBER
..
28. NAME AND ADDRESS OF PERSON WHO CERTIFIED THE CAUSE OF DEATH (ITEM 3'IITwoJPrlnI/
.:J'\-llø'i S' 21- L"'r
27d. DATE SIGNED (1.10.. Day, Yr.)
O{)P~ 21 ,'1'1 \.
John H. Ward
29, REGISTRAR'S SIGNATURE
31. PART' ENTER THE DISEASES, INJURI ,OR COMPLICATIONS THAT CAUSED THE DEATH. DO NOT ENTER THE MODE OF DYING, SUCH AS CARDIAC
OR RESPIRATORY ARREST. SHOCK. OR HEART FAILURE, I.IST ONLY ONE CAUSE ON EACH LINE.
MdM"'c. fn",,~~/'P~
'f"lt,1t Mjdc.rn(l..
IMMEDIATE CAUSE IFiMI
diI.'HOfOØlfdiffor:
"JuIItng"dfltlt}
.,
REGISTRAR
.,.
DUE TO lOR AS A CONSEQUENCE OF):
b,
I 'f¿ J~IIf)
SoquentIallv ill_,
" In,. leading 10 Ifr.mec:blle
cau.a, Ent.. UNDERLYING
CAUSE ,dis.". or II'IJUIY
""'itHf;'lfId~rs,.suItinø
In deallllLAST
DUE TO lOR AS A CONSEQUENCE OF):
,.
DUE TO (OR AS A CONSEQUENCE OF):
j CAUSE OF PART II. OIhar Signll,'anl Cond,"on. conllibullng 10 de.1h but nol 32, IN YOUR OPINION, TOBACCO USE BY THE DECEDENT 33., WAS AN 33b. WERE AUTOPSY ~
OEATH 01. Probably conlribuled 10 Ihe ca..a 01 dealh. Dr 5, NON.USER AUTOPSY FINDINGS AVAILABLE
02, Was the underlytng caUl. of death. PERFORMED' ~'g=UT~ ~~~L¡TT~~N
o 3, Ood nol çont,obute 10 the eau.. 01 de.'h, 0 6, UNKNOWN 0 r.\
04, Is unknown in 'elatIon 10 the cause of death, IF USER t. Ve. ""^ 2, No 0 1. Yes 0 2, No
3', MANNER OF DEATH 35a, DATE OF INJURY (Mo.. Da), y,.} 3Sb. TIME OF INJURY 35c,INJURY AT WORK' 35d, PLACE OF INJURY, AI home, 'arm, Slre,'.laelo'Y,
, ~.h__~.~" ,"__ ___,_, ;
~ üJ t. Nalural 02, Aceidenl 0 t.Yos 0 2, No 1
f 03. Suleode D., Homleode 35e. LOCATION (5,,_r 0' ..,.., ,au.. ,"''"..., "'''' 0' "",,", counIy.nd "·..·1 351, ~::~~::::;:.c~~;~::.::~v il decedenl was ~i
t 0, 0 3Sg. DeSCRIBE HOW INJURY OCCURReD cenle, seQUence 0' eyents wtuch ,esullod In rn Of)'. NATURE Of INJURY SHOULD Ði... E
t 5. UndetermIned 6, Pending _ \'"
~~~~':::Iy Of Investigllllon C,
: Th I Aceod.n"'''y 1
Information on file In this office. This certified ..... J
copy Is issued under authority of Section 26-15-26 -<_~
of the Utah Code Annotated, 1953 as amended. ;-. 1
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Date Issued