HomeMy WebLinkAbout925415
000797
RECORDED AT THE REQUEST OF,
AND WHEN RECORDED, MAIL TO:
Cynthia J. Crass
CALLISTER NEBEKER & McCULLOUGH
Gateway Tower East Suite 900
10 East South Temple
Salt Lake City, Utah 84133
,REC VED 11/20/2006 at 1 :22 PM
, RE VING # 924575
BOOK: 6 PAGE: 723
JEA WAGNER
LINCOLN COUNTY CLERK, KEMME ER, WY
AFFIDAVIT OF SURVIVORSHIP
STATE OFUTA...q )
: ss.
COUNTY OF SALT LAKE )
Bessie Oblad, being duly sworn, deposes and says:
1. That Affiant is oflegal age, a resident of Salt Lake County, Utah, and competent to make
this Affidavit.
2. That Affiant is the surviving spouse of Alex G. Oblad, deceased, who died on September
19,2000.
3. That Affiant and Alex G. Oblad, deceased, appear of record as co owners of certain real
property located in Lincoln County, Wyoming more particularly described as follows:
Wcr~+~,lb
W...->lv~lle Subd Lll Total 4.94 acres T3l R1l9 S4
GEO PIN 3119-04-2-00-162-00
4. That due to the death of Alex G. Oblad she is now the sole surviving owner of the real
pfUp~rty described in paragraph 3 above.
ßQ~ ar~
Bessie Ob.la ¿¡;y' C~? 0
//j ~¡J()Ôtl hé' Ý
SUBSCRIBED AND SWORN TO before me this ----L- day ofS~ber 2006, by Bessie
Oblad, personally known to me or proved to me on the basis of satisfactory evidence to be the
person whose name is signed on the preceding document, who duly acknowledged to me that (s)he
executed the same voluntarily for its stated purpose. r2ú}L
NOTARY PUBLIC N~;t. Y PUBLI
CYNTHIA J. CRASS
10 E. South Temple. 51e. 900
S4illlake City, Utah 84133
My Commission Expires
March 1, 2009
STATE OF UT H
476617.1
RECEIVED 12/18/2006 at 11 :53 AM
RECEIVING # 925415
BOOK: 643 PAGE: 797
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
::iIAIt:VI" U IAH - Ut:I"'AK I Mt:N I VI" Ht:ALI H
CERTIFICATE OF DEATH
!Ieee" 10 information 01'1
09 1h·_·~FILENUMBER 18-4022:
. 1. NAME OF DECEDENT FIRST
Alex
4. DATE OF BIRTH (Mo.. Day. Yr.)
November 26, 1909. 90
eo. PLACE HOSPITAl (-.-. ..._.....,~ AlL OTHER LOCATIONS:
~EAO: I DI.lnpollent I 0 ~. Nursing Homl I!J 6. Rllldtnct (Illy)
one) 02.ERlOutptllent 03.DOA 07.0Ihtr(lpoci(y} 1415 South Roxbury Road
Be. CITY. TOWN. OR LOCATION OF DEATH ed.COUNTY OF DEATH B. SURVMNG SPOUSE (1f..1t, I/Í.....-n nome)
Salt Lake City . Salt Lake Bessie Elizabeth Baker
10.~~ VJ-¥~gtNJ: 11. MARITAl STATUS 121. DECEDENrS USUAL OCCUPATION (Give/dndalworlrdone 12b. KIND OF 6USINESS OR INDUSTRY
ARMED FORCES? o 1. No....Motriod0 3._ ch1ttn¡¡_ofworldngNIt. DoNOTen/errellr8d)
01. YnlID 2. No ¡] 2.MorrJod 04.DI_ Professional Emeritus University of Utah
MIDDLE
STATE FILE NUMBER
30. DATE OF DEATH (Mo., Day. Yr.)
LAST
DECEDENT
138. RESIOENCE - STREET ANO NUMSER
130. COUNTY
13d. STATE
1415 South Roxbur
130.INSIOE CITY 131. ZIP CODE
LIMITS7
~ 1. Yel 84108
02. No
Road
14. WAS DECEDENT OF HISPANIC ORIGIN?
(/lyes, Spfdfy)
o XMexlcan 0 2. Cuben
o 3.P1Jorto Rlcen 0 4. Other (SpocIfy)
Salt Lake Cit Salt Lake Utah
o 1. Y," ~ 2. No 15.::; ¡I:'~:':;"'~), 16. ::.c::,o':f:i:m":t~":;'
JopeneH, lie. (Specify) Soa>ndory (0-12) College (13-16
...11+)
Caucasian
17+
18. MAIDEN NAME OF MOTHER (FItsI, _. Leat)
Louie May Brewster
PARENTS
11. FATHER'S NAME (FIrs!, Middle, Lest)
Alexander HugoOblad
INFORMANT
lB. NAME, RELATIONSHIP AND MAILING ADDRESS OF. INFORMANT
SON: Alex EdwardOblad/4650South Buttonwood Drive / Sandy, Utah 84092
20. METHOD OF DISPOSITION 21~D"TEOF DISPOSITION 21b. ~~ 2-1:c;,S~~ (..... 01-",. 21e. LOCATION - City or T-., SIoIo
0'. ~nt""'''''''·DZ.'''''''''IOOD ,.o"'"':'·:·>·Sepf:"2j~···200 Larkin Sunset Lawn Salt Lake City, Utah
Cemetery
~
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;g
CERTIFIER
DISPOSITION
23. LICENSEE NUMBER
22-113395
24. FUNERAl HOME (N.... end _"")
Larkin Sunset Lawn
2350 East 1300 South
SLC Utah 84108
DC{( <.
REGISTRAR
IMMEDIATE CAUSE (F/na)
disease or condllion resulUnI1'
In dee/h)
~""'J t
..'-' ,..:-,"~- I~~ - .......___
DUE TO. (OR AS A.CONSEQUENCE OF):
O-~ t!-
f.-o
o.
Sequentlelly list còndltlons,lI
any, leading to Immediate
cause. Enter UNDERLYING
~~I~~~ ~~:~"~~I~~nlhat
deolh) LAST
b.
DUE TO. (O~ AS.A Co.NSEQUENCE OF):
e.
DUE,TO (OR AS A CONS~QUENCE OFI:
d.
CAUSE OF
DEATH
~~e= tlgnlht~~~':':~I=~"::' '1"0111 32. IN YOUR o.PINION, TOBACCO USE BY THE DECEDENT:
. ..' 0 ': Proboblyconlributod tolho ceuso 01 delllh. ~N USER
o 2. WII.1he underIyi1g couso of ....th.
[J ;~', DId,~OI ~JbuI. 10 the CItUM of de.th.
. O:4~.'ÎI ~ ,In ,.eøuon to the cauH of death.
35..... Dl\TE OF INJU.RY (Mo., Day, Yr.) 35b. TIME OF INJURY 35c. INJURY AT WORK? 35d. PLACE QF INJURY - AI "º""" fotm, streeI, fac:IrJIy,
.. . . ..' '.' . .' (24 Hour CIOCI<} 0 ,. Y.. 02. Nø øfIfce. building, etc. (sptdfy)
350. LOCATION (SbHI or rurol """" nuntber, city or /own. county ond stIlt.) 351. ::.~:æ~~J: specify W docodonl wel driver.
330. WAS AN AUTOPSY 33b. WERE AUTOPSY
PERFORMED? FINDINGS AVAIlABLE
PRIOR TO COMPLETION
OF CAUSe OF DEATH?
UDH-BVR
Form 12,
R.v. 12/98
08. UNKNOWN
IF USER
01.Y.I ~
o I.YoI D 2. No
This is to certify that this is a true copy of the certificate on file in this office. This certified copy is issued
under authority of section 26-2-22 of the Utah Code Annotated, 1953 As Amended. .
§ Date Issued: SEP 2 5 2000 .
U1
~ County - Salt Lake
>
aJ
±
o
UJ
B~t~
Barry E. Nangle
DIRECTOR OF VITAL RECORDS
By
Registrar
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