HomeMy WebLinkAbout927733
II
000828
6010715058
RECEIVED 3/20/2007 at 3:39 PM
RECEIVING # 927733
BOOK: 651 PAGE: 828
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDA VIT
STATE OF WYOMING )
)ss
COUNTY OF LINCOLN )
I, C. Dennis Walton, being first duly sworn on oath, depose and say:
That I am a citizen of the United States of America and over the age of 21 years, and
a resident of Afton, Wyoming.
That I was well and personally acquainted with Loren Walton as described in that certain
Warranty Deed dated January 22, 1979 and recorded September 19, 1994 in Book 357PR on
page 513 of the records of the Lincoln County Clerk.
\,
That I know of my own knowledge that Loren Walton in the above described Warranty
Deed and mentioned in the attached Certified copy of Certificate of Death was one and the same
person.
This affidavit is intended to terminate the life estate of said Loren Walton in the
following described property:
Beginning at the southeast corner of Lot 1 of Block 9 of the Afton Townsite,
Lincoln County, Wyoming and running thence North 74.5 feet, thence West 135
feet, thence north 2 feet, thence West 30 feet, thence North 6 feet, thence West
8.5 rods, thence South 5 rods, thence East 18.5 rods to the point of beginning.
Dated this J CJ 1J, day of March, 2007.
r;.'?~ Æ4¿1¡b
C. Dennis Walton
State of Wyoming )
)ss
County of Lincoln )
. Jhe foregoing instrument was subscribed and sworn to me by C. Dennis Walton this
~ day of March, 2007.
Witness my hand and official seal.
My Commission Expires:
9-/6·C;7
~~M~
Notary P he
GLORIA K. BYERS· NOTARY PUBLIC
County of State of
Lincoln Wyoming
My CommIssIon Expires Sept. 15, 2007
V-.J-· . --
~ ,"',.... "'. ... - ..... - --
TYPE
ORPA'"
IN
PERMNENT
IIL'CK
INK
FOR
INSTRUCTIONS
SEE
HANDBOOK
LOCAL FILE NUMBER
1. DECEDENT-NAME FIRST
MIDDLE
LAST
2. SEX
STATE FilE NUMBER
3. DATE Of DEATH iMo.. Day, Vi..I
000829
4fi:J.
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
256 Jefferston Street
8. STATE OF StATH tll nof t1 U.s.A.., natrHt OOIJI'IItY.I
Male
5c. UNO R 1 DAY
Mlnulel
Ma y 22, 1 99 5
6. DATE OF BIRTH (Mo.. Day, Yr.'
Loren
4. socw. SECURITY NUMBER
January 15, 1915
7.. PlACE OF DEATH IGhecIf only one'
1J2§fIJðL' Q!I:ItB,
o lnp.lt6en1 0 ER/OUlpfilient ODOA 0 Nurling Home
lb. FACIUTY NAME tit noI lnaUlullon. give sfte" MJd runb8(.I
lXAesldence 0 DIMr ISpeclty)
7c. CITY, TOWN. OR LOCATION OF DEATH
7d. COUNTY OF DEATH
Lincoln
No
,3&. AESK)ENCE - STATE
13b. COUNTY
g, MARRIED, NEVER MARRIED, 10. SURVIVING SpOUSE III wll., give maiden name'
WIDOWED, DIVORCED tSpllCilyJ
Married Ann Dana
12.. USUAL OCCUPATHJN (GIw kind of wen don. dlXlnfl most 12b. KIND OF BUSINESS OR tNDUSTRY
01 WClfIrIng IJ,., .., II ,elinJd,
Laborer
13c. CITY, TOWN OR LOCATION
Jefferson Street
6, DECEDENT'S EDUCATION
(Specify only Nghøl rI'**' COIfV)IeledJ
Elementary/Secondaly 10-12 CoIIeQ41 (1-4 or 6+)
White 7
Mliiden &.name
II,
Lincoln Afton
14. WAS DeCEDENT OF HISPANIC ORIGIN?
Speclly no Of yel - II yel, apeclly
Cuban, Mexican, Puerlo Rk:an, Ele.1
Fifat
Charles
N~ v.. 0 (Specify'
Middle Las'
Lorenzo
Walton
'8. MOTHER'S NAME Firat Middle
Mary Amelia
Jorgenson
'\,
"
1u..INFORMANT-NAME (TypI 01 Prlnll
Ann Walton
19b. RELATIONSHIP TO DECEDENT
Spouse
I'
19c. MAUNG ADDRESS
STREET OR R.F.D. NUMBER
CITY OR TOWN
83110
STATE
ZIP COOE
P.O. Box 382; Afton, Wyoming
. I
PM
lòg
L
A~
.!I [I¡
,20
23c. HOUR OF OEATH
23d. PRONOUNCED DEAD (Mo., a.)'. YT.'
M
231. PRONOUNCED DEAD IHOUI'
M
24. NAME AND AQOAESS OF CERTIFIER (PHYSICIAN OR CORONER)(Type Df PrInlJ
Orson D. Perkes, MD; 110 Hospital Lane; Afton, Wyoming
83110
25.. REGISTRAR
25b. DATE RECEIVED BY REGISTRAR (Mo., Oar. Yr.'
51....1 ~
PART I. Enler lhe diseaa... ¡flu,I,., or c teal lhat caua.d death. Do nol enter lhe mode 01 dying, such u cardiac
26. or ,..pltatory arr..... shoc:k, or heart faüure. Ual 0tM'f one calAe on ..en line.
IMMEDIATE CAUSE (Anal ~
...,... ... <""""Ion f) 11 )( m. - I
rolUlling In dellhl .. L {Y ' L. u c.A....J
DUE TO ( AS A. cåÑSEOUENCE Of):
ý~:>--7~
b,
DUE TO (OR AS A CONSeQUENCE OF :
Approximate
Ilnlelval8elween
i~I"~
:t'i' ~
I
,
I
,
,
I
I
,
Sequentially Oat condiUons.
II any,.adInQ to Immelia\l
~u... Ent_ UNDERLYlHG
CAUSE (DI..... Of Injury
thai ¡nI....1ed .vent.
,....lIng In deathl LAST
DUE TO lOR AS A CONSEQUENCE on
ø
':>\)
~~
d,
PART II. OTHER SIGNIFICANT CONOITIONS·CondIIIonI çonlr buling to dealh but nol ,.lIIted 10 caUl8 given In PART I.
27 AUTOPSY (Specify 28. WAS CASE REFERRED TO CORONER
No yat ... no (SpocU, .... "' nol No
29. MANNER Of DEATH
...h..... 0 Pending
Invullgallon
:J0a. DATE OF I >¡JURV
(Monlh, 0_... Yea-'
30b. TIME OF
INJURV
30e. INJURY AT WORK?
, Speciry )'86 Of no)
3Od. DESCRIBE HON tNJURY OCCURRED
VR 2-89
2/91 15M
Sulcldt
o Could not be
Delermlned
M
30e. PlACE OF INJURY-AI home. l.rm,llfeel. factory.
olliee building, atc./s,..œvJ
301, LOCATION ISlreel and Numbe' Of Rural Roule Number, CiI'f or Town, SIale)
-,
Homicide
THIS I~ TO CER~IF: that this reproduction is a true copy
of a record on file In Wyoming Vital Records Services
Cheyenne, Wyoming. '
T,his copy is not valid unless it bears a raised seal and the
signature of the Deputy State Registrar is in red.
Date Issued
JUN - , I9æ
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