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Home My WebLink About930863 000243 A FFTDA VTT The State of Wyoming ) : ss. County of Sweetwater ) FLOYD R. MILLER, of lawful age, being first duly sworn upon his oath according to law, deposes and says: 1. That Harvey D. Miller died intestate at Rock Springs, Sweetwater County, Wyoming, on June 18,2000. 2. That on the 8th day of July 1996, Harvey D. Miller and Anna May Miller, husband and wife, purchased the following described real property from Leisure Valley, Inc., a Nevada corporation: Star Valley Ranch RV Park Plat One Lot 359 as platted and recorded in the Official Records of Lincoln County, Wyoming Reserving therefrom all rights, title and interest III and to any and all mineral rights appertaining thereto. Subject to all declarations of covenants, conditions and restrictions of record. 3. That Leisure Valley, Inc., a Nevada Corporation, duly and regularly executed a Warranty Deed dated July 8, 1996, in favor of Harvey D. Miller and Anna May Miller, husband and wife, as joint tenants, Grantees, which Warranty Deed was filed for record in the office of the County Clerk within and for Lincoln County, Wyoming, on the 30th day of July, 1996, in Book 386PR on Page 377, Reception No. 823912. 4. That at the time of said purchase, and the execution and delivery of the above-described Warranty Deed, the conveyance of the real property hereinabove described was made to Harvey D. Miller and Anna May Miller, husband and wife, joint tenants, and they owned and held the title to said real property as joint tenants continuously from said July 8, 1996 until the death of Harvey D. Miller on June 18,2000. 5. That Anna May Miller survived Harvey D. Miller, and by virtue thereof, said joint tenancy vested in her upon the death of said Harvey D. Miller and that she then became the owner in fee simple of all the real property held as such joint tenants hereinbefore particularly described until her death on November 28,2006. 6. That this affidavit is made in accordance with the provisions of Wyoming Statutes, Section 2-9-102 (Lexis 2005), and that the Certificates of Death hereunto annexed, and by this reference made a part of this affidavit, are copies of the official death certificates of the decedents, Harvey D. Miller and Anna May Miller, certified to by the public authority in which such original death certificates are made of record. DATED this /~ day of June, 2007. RECEIVED 7/2/2007 at 10:39 AM RECEIVING # 930863 BOOK: 664 PAGE: 243 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY 1 O~Ki0863 The State of Wyoming County of Sweetwater ) 000244 ) :ss. SWORN to before me this /~ day of June, 2007, by ~fadíP My Commission Expires: 11 élJ ;:)()jj 2 0930863 \ 'l'VU;':4S This is a true and exact reproduction of the document on file in the office of.\(ital,Hecords Services, Cheyenne, Wyoming. !;j\" ," /' Gladys K. Breeden Deputy State Registrar , I , This copy is not valid unles~it bears a raised seal anètis produced on multicolored,securitY, paper. ../ 04J1140 / 83 I.OCM. PU....... ' . . STATE OF WYOMING DEPARTMENT OF HEALTH CERTIFICATE OF DEATH 2000-001 721 I1I1II I'LI_ ~ 1 U June 18. 2000 .DA1II1JI'1IIIIt1.... -..ItJ February 26. 1927 .. I:.. HARVEY .._ CUI'I1Y..- ,..PUJClIJI'..mt_...., _I tIIIIDI,; C_ JIIII~ CDDA !IIII\It ?It. ""'-"""___' Memorial Hos Itnl of' Sweetwater ',1I1I\1I1JI'1IIIII/...... __I "'Wyoming U,·_I..CI!ØI...... ..u.a. __.? /.....,.* .. 11>/ \ Yes. .,,,,,,.. ._ '3I>COUNTY SweetwÁter IQ/I1RY Sweetwater Rock Springs ... VNDlÇIIIIfIJl'__ (_..........,.,...,. . ____1kI NaJfJ _01-.' - ..... Bverett .vMiller '." ~ -,", : '" ,'-. '!è~Ru~red Myocardial Infarct < ~. ,:~.OftM_AOONaQUlllll;l.OfI: -- 1.........-.-' ".1IiII1JI' 300._111_' IU.IW ,___.'. NI' ",:.¡-;;:,1'<'::'::- ,~,:- ',,""." rDays ,; " :" ". !Years.., I , ., . "..":: ,~-::;·'(fJ~.~ Disease _It ";;"~:~~1~ .,'_,,-6" --,~~·3¡-:· " '~'/'" M. _ IWIIY...____, __....,.....,' ...-..---. .. -! ;,:, ¡ÌJii/\¡'. ...,."~-'';;':,::, ..., 'i~/ ,..:' -- 09tj08GJ LOCAL FILE NUMBER 174 STA1_ _. .. (OMING DEPARTMENT OF HEALTH CERTIFICATE OF DEATH 000246 1, DECEDENrS LEGAL NAME (lócJ,ude AYJI. H .ny) (FIJlI. MIddI.. Laol) 2. SEX 3. DATE DF DEATH (MoIDay/Vr) (span Month) ANNA MAY MILLER Female November 28, 2006 4. SOCIAL SECURITY NUMBER' 5L AGE - Laol Birthday I 5b. UNDER 1 YEAR I 5e, UND RI DAY 8. DATE OF BIRTH (MoID.y/V,) (Y~",) 76 I Montho I Dayo I Haura 1 Mln.... July 27, 1930 7.. PLACE OF DEATH (Ch.ek onlv on. IF DEATH OCCURRED IN A HOSPITAL: IIF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL: XJ Inplllanl o ER 10ulpallant ODOA o Hooolc, F.cllllv 0 Nu..ln. Homo I Ulna 'norm CI.. Flcllllv o Deœdlnr. Hom. o Olhl' (SoaclM >. 7b. FACIUTY NAME (If notlnatilullon. gM .1nI.t end number) /7e. CITY. TOWN. OR LQCATION OF DEATH 17d. COUNTV OF DEATH m Memorial Hospital of Sweetwater County Rock Springs Sweetwater "0 a: ~g a. BIRTHPLACE (CUy Ind atlte 0' I.relgn counlry) 18. M6BITAL STATUS AT TIME OF DEATH 10, SURVIVING SPOUSE (If wH., give name prior 10 nllt marriage) "u Evanston, Wyoming o M.rrled 0 M.rrI.d. bul.lparal.d (X WIdowed ~~ j Divorced j N0\/8' Merrlld j Unknown 11. EVER IN U.S, /12.. RESIDENCE - STATE , /12b. COUNTY 12e. CITY. TOWN OR LOCATION SQ ARMED FORCES? Wyoming Sweetwater 11)...1 DYES at NO , Rock Springs ã..< sa: 12d. STREET AND NUMBER 12.. ZIP CODE 12f. INSIDE CITY LIMITS? oW 514 "I" Street 82901 UZ C(YES 0 NO 11)::1 mil. 13, FATHER'S NAME (A"L Mlddl., Laol) 14, MOTHER'S NAME PRIOR TO FIRST MARRIAGE (FI"L Mlddl., Laol) ~ Theodore Mills Hazel Farley 150. INFORMANrS NAME T 15b. RELATIONSHIP TO DECEDENT 16e, MAILING ADDRESS (StrOll and Numb.., Clly. SI.II, ZIp CadI) Floyd R. Miller Son 700 Schultz Space 3, Green River, Wyoming 82935 18. METHOD OF DISPOSITION 171, PLACE OF DISPOSITION (Naml of 17b. LOCATION - CITY OR TOWN AND STATE QtBUrlal o Donation o Ramoval from Wyoming ~I comHlry or eremalory) o Cremation o Enlombment o Othe, est aven Memorial Gardens Rock Springs, Wyoming ;r::1:~S7'ENSEE I 18b. LICENSE NO, 181, NAME OF FACILITY 18b, ADDRESS OF FACILITY 485 Vase Funeral Home 154 Elk Street , Rock Springs, Wyoming 82901 20. ACTUAL OR PRESUMED"tIME OF DEATH 121. DATE PRONOUNCED DEAD (MoIDlY/V') 122. TIME PRONOUNCED DEAD 23. WAS CORONER CONTACTED? 1742 November 28, 2006 1742 DYES III NO CAUSE OF DEATH I I 24. PART I. EnI..1ha chain 01 avanll - __, Injuria. or compJIcallona -lhal dtractly ca...d Iha dealh. DO NOT .nt., l.rmln.1 avanll IUch al cardiac I A>proxlmal. Interval: ."""1. reoplratory arraol, a' vantrtcutar IIbrlllation wIthoul ohowtng thl .11oIogy. DO NOT ABBREVIATE. EnI81 only ana cauo. on 1Ilnl, Add addlllonalllna. Oneal 10 ,dealh If nacoU8JY. I IMMEDIATE CAUSE (FInal dloaaOl or lulmonary Embolism I 2 Hours condIllon ....lIIng In delth) DUE TO (or u a _qulnca oQ: I I S8quantially llal COndIllona, " any, peep Venous Thrombosis I Days loading 10 tho cauaellated on IIna a. I Enler Ihl UNDERLYING CAUSE (die.... or Injury that initiated Ihl DUE TO (or u a con..qUlnca oQ: I avanl./loulllng In delth) LABT. I Esophageal Cancer I Months 0. DUE TO (a' u a eonuqulnce oQ: I I I d. I : >. PART II. Enla' othor .Ignlftcant condlllona conlrlbuting to _ but notraoulting In Ih. und.rlylng cau.. glvln In Plrll. 25. WAS AN AUTOPSY m PERFORMED? 'ia: DYES I!!INO O¡W 28. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? 27. DID TOBACCO USE CONTRIBUTE TO DEATH? ã..lI: S¡: DYES ONO DYES ONO JD PROBASL Y o UNKNOWN 8ffi 28. IF FEMALE AGED 10-64 29. MANNER OF DEATH 11)0 o Nol pregnanl within pul ya.. o Not pregnant, bul pregn.nl43 dayo 10 1 YOII b.lo,. dlath " JD N.luJl' CI Homlcld. m o Pregnanla! limo 01 dealh o Unknown II pregnlnl within Ih. pall ya., .0 A_nl o Pending rnvullgation {? o NOI pregnanl, but pregnant within 42 deyo 01 death o Suleldl o Could nol b. dltermln.d 30. DATE OF INJURY (MoIDay/Vr) 131. TIME OF INJURY /32, PLACE OF INJURY (DlCOdanr. ham., conltruollon alii, loreot, Itc.) 33,INJURY AT WORK? OVES ONO 34. LOCATION OF INJURY (SInI.1 and numb." CUy or Town. Stell) 35. IF TRANSPORTATION ACCIDENT. SPECIFY: o Drive, I Operato, j Pldellrlan o Pal..n.., o Oth.r ISDac"") 38, DESCRIBE HOW INJURY OCCURRED, AND IF TRANSPORTATION INJURY, THE TYPE(S) OF VEHICLE(S) INVOLVED. (Aulomoblll, pickup, motorcyctl, ATV, blcycl.. .10.) 37";¡6ERTIFIER (Check only ona) PHYSICIAN - To thl bul of my knowledgl, death occurred II thl lima, dala and placo, end due 10 thl cau..(.) and mannll .""d, o CORONER - On tho bule oI.xamlnallan. and/o, """'.tlgallon. In my opinion, d..1h occurred allhl Ilml, dala .nd placo. Ind due to tho o.u..(.) and mamer .teted. Signalure 01 CaJtinlr . ~ , 37b, DATE CERTIFIED (MoIDay/V,) 1 37e. NAME¡,~ ~F CERTIFIER (Typl or pMI) November 30, 2006 John Iyá! M. .,1208 Hilltop Drive Suite 105, Rock Springs, Wyoming 82901 388. REGISTRAR'S SIGNATURE ~-' S( /\ 38b, DATE RECEIVED BV REGISTRAR (MoIDay/Vr) ~j , November 30, 2006 STATE FILE NUMBER December 1, 2006 , THAT this is a true cocrect conformed reproduction of the original ", 'ficate completed by the VASE FUNERAL HOME and submitted ",,;.·'_.~S SERVICES. Wyoming Department of Health and Social Services. Divisi. . ~fu··4fid Medical Services at Cheyenne, Wyoming. ~'- ;,~.>t'~:"~~. -< ~ ~~~ g: s~~~ss , . VASE FUNERAL HOME Subscribed and sworn to before me a Notary Public 154 Elk Street .. ho Ij 1 ~ December 2006 Rock Spnngs, WyoInlng 82901 t ~ .' _ ì ay '~ My commission expires on April 21, 2010