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000155
AFFIDA VIT
STATE OF WYOMlN{} 'XOA-I+C'
RECEIVED 2/6/2007 at 10:20 AM
RECEIVING # 926561
BOOK: 648 PAGE: 155
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
COUNTY OF1..INCOLN B/tJ6-H'11-1r\
I, Norma L. Day, being first duly sworn on oath, depose and say:
That I am a citizen of the United States of America over the age of 21 years, and a
resident of Lincoln County, Wyoming
That I was well and personally acquainted with Norman L. Day in that certain Warranty
Deed recorded October 22, 1990 ,Book 291PR P.R., Page 31
in the office of the Recorder of Lincoln County, Wyoming.
That I know of my own knowledge that Norman L. Day in the said deed and Norman
LeRoy Day mentioned in the attached Certified Copy of Certificate of Death was one and the
same person.
This Affidavit is intended to terminate the joint tenancy (the life estate) of
Norman L. Day in the following described property:
Lot 722 Lakeview Estates Ninth Addition, Lincoln County, Wyoming, according to that plat
filed September 26,2005 in the Office of the Lincoln County Clerk as Instrument #912220 and
Plat No. 250-G.
~~~ ¡)¥=
Norma- . Day
Subscribed and sworn to before me this (~
day of February, 2007.
Residing in: F_U\ctéÇObl-
Commission expires
08JZS/1ÞIZ.-
;j, .l~ltlCQ to 'W""~5
Notary Public {
'-
. 09Z6S61
STATE OF ARIZONA
.-- - -------"--.-
000:156
ORIGINAL
STATE
COpy
STATE OF ARIZONA
DEPARTMENT OF HEALTH SERVICES - OFFICE OF VITAL RECORDS
CERTIFICATE OF DEATH
NAME OF
DECEASED
1.
RACE (..g., whit., bI.cIc. American Indian, (opocIfy lribo)olo.
SPECIFY: W hit e
4....
PLACE OF
DEATH
....RRST
B. MIDDLE
DEATH NO.
D.1022007. 000328
NORMAN
LEROY
C. lAST
DAY
SEX D"'TE OF MONTH
MALE DEATHJANUARY
2. 3.
IF YES, INDICATE MEXICAN. SPANISH, PUERTO RICi\N,
CUBAN, ETC.
D...Y
3 ,
YEAR
2007
M COUNTY
Maricopa
WAS DECEDENT OF HISPANIC ORIGIN:
(SPECIFY YES OR NO~ 0
4B.
6B. TOWN OR crTY
Phoeriix
4C.
00. HOSPITAl OR
B INSTITUTION
anner
WAS DECEASED EVER IN U.S. ARMED FORCES?
(SPECIFY YES OR NO)
No
5.
(IF RESIDENCE. GIVE STREET ADDRESS)
6.
DATE OF
BIRTH
7. February
Estrella
Hospital
60.
ODDA
o OP EMER.
:xtJ IN PATIENT
pF WIFE, GIVE MAIDEN NAME)
MONTH
DAY
YEAR
IF UNDER 1 D...Y MARRIED, NEVER MARRIED, SURVMNG
HAS. MIN. WlOOWED, DIVORCEO(SPECIFY) SPOUSE
sMarried mNorma
SOCiAl SECURITY NO. USUAl OCCUPATlQI\I (GI.. I\Ind of....
dc_~stpl wondrlj,llili._1f&IdI.d¡
13. 1~·-a-J;.n't·e n-an-c'e
150. ZIP CODE HOW LONG IN AmZONA?
13,
1932
15J. 2 7
Stoor
83128
PREVIOUS ST"'TE
OF RESIDENCE
1..Wyoming
MOTHER'S MAIDEN
NAME
L. Williams
KIN ) OF BUSINES1 QR INDUSTRY
. CHEMICAL. . .
14B.Company
EDUCATION
HIGHEST GRADE COMPlETED
STATE AND
CITY OF BIRTH
Weston,
(II net In USA. n.... CCUnlly)
USUAl
RESIDENCE
!5.Wyoming
STREET ADDRESS OF R.F.D.
15.4. STATE
1.5 Months
17.
ELEMENTARY SECONDARY
(0-12)
F"'THER'S
N"'ME
19.
INFO
....RRST
Leland
A. FIRST
1.....
B. MIDDLE
'.B.
C. lAST
COu.EGE
(1-40.5+)
1
20.
Novis
Estelle Payne
CIT'(ANDSTATE .... . ZlPCODE
Alp~ne t Wyom~ng
83~28
21.~ Norma L.
BUR !I",ÇftIiWl1&»'!, /
REMlM'It;: 0'f~8pkIfy)
J3urial
FUNERAl HOME
Sonoran
2..
Day
D"'TE
~17.
STREET Np.
Stoer Dr~ve
25.
NAME
Skies
1/15/2007
CERT. NO,
5650
E.
St.
27J. 203
CERT. NO,
29A.~hri s tin e 3181211
ON THE BASIS OF EXAMIN...TlON AND/OR INVESTIGATION, IN MY OPINION DEATH OCCURRED
"'TTHETlME, DATE AND PLACE DUE TO THE CAUSE(S) AND MANNER ST"'TED.
TO THE BEST OF MY KNOWLEDGE, DEATH OCCURRED "'T THE TIME. D"'TE AND PLACE AND
DUE TO THE CAUSE(S) STATED. . .
30. ~~~~RE ~ .
~ >-
ug
õ.~~
E E ü
811; -
lIu~
~ t
HOUR OF DEATH
36.
PRONOUNCED DEAD (Hour)
38. AT
MEDICAL EXAMINER'S SIGNATURE
D"'TE RECf) IN ST"'TE OFFICE
46.
APPROXIMATE
INTERV...L
BETWEEN
ONSET
AND
DEATH
PART II. Other 81nnlficant ~vmitlonø contributing to death but not resulting In the underlying cause given in Part I
48 Ib 1'5
MANNER OF DEATH DATE OF MO D"'Y YR
0= DH:MŒE INJURY
DÞroŒNT Dr=.ID-I
61, Dwaœ Dl.I'-Œlm1t>ID 66,
SUPPLEMENT"'RY ENTRIES
60.
W"'S CASE REFERRED TO MEDICAL EXAMINER
(SpeoIfyY.. "'No)
No
STREET ADDRESS
CITY OR TOWN
ST"'TE
,'" '. ,I '-
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