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000260
Affidavit of Survivorshm
State of Wyoming )
) ss.
County of Lincoln )
MICHAEL FAUBER, being first duly sworn upon HIS oath, deposes and states as follows:
1.0n the JANUARY 17, 2007, my FATHER, RONALD DAVID FAUBER 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 father 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:
LOT ONE (1) OF THE BRIDGER FOREST RANCH SUBDIVISION, AMENDED, ACCORDING TO THE
OFFICIAL PLAT THEREOF RECORDED FEBRUARY 6,1975 AS MAP NUMBER 116 AND INSTRUCTION
NUMBER 463684 IN THE OFFICE OF THE CLERK, LINCOLN COUNTY, WYOMING.
3. Said real property was originally conveyed to RONALD D. FAUBER A SINGLE AND MICHAEL
FAUBER A SINGLE MAN, by WARRANTY DEED, dated AUGUST 23, 2005, and recorded in the office of
the Lincoln County Clerk and Ex-Officio Register of Deeds on AUGUST 29, 2005, in Book 595 at Page 779.
4. By reason of RONALD DAVID FAUBER's death, I am entitled to sole ownership of the
above-mentioned real property.
Dated this MAY 15, 2007,
¿YSi ~
MI H FAUBER
Subscribed and Sworn to and acknowledged before me this MAY 15, 2007, by MICHAEL FAUBER.
Witness my hand and official seal.
HEIDI ROBE.RTS NOTARY PUBLIC
COUNTY OF . STATE OF
LINCOLN WYOMING
MY COMMISSIO.~ EXPII'fES~.16.2010
i;;L~ f?iwcf-
N tary Public
RECEIVED 7/10/2007 at 2: 11 PM
RECEIVING # 931139
BOOK: 665 PAGE: 260
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
4. SOCIAL SECURITY NO.
REGISTRAR'S NUMBER
UI't
I ,... -
fl.' ~J1 ~,p;;!. t'; lw
BLACK INK.
FOR
STRUCTlONS
E HANDBOOK.
REGISTRATION DISTRICT NO. I ï J
1. DECEDENrS NAME (Firsl, Middle, L.ast)
Januar 18, 2007
7. BIRTHPLACE (City .nd 51818 or Foreign Country)
Campbell COlmty, Virginia
8. WAS DECEDENT EVER IN
U.S. ARMED FORCES?
(XVes DNo DUnk.
o Inpatient 0 ERlOutpatient
o Residence ¡¡o Other (Specify) Hotel room
9d, COUNTY OF DEATH
Saline
13d, ZIP CODE
45778
JOO
9b. FACIUTY NAME (If not Institution, give .t",.1 .nd number)
1355 W. College, Room 120
a:
o
~
~
f
~
ill
:>
~
Ohio
130. STREET AND NUMBER
Athens
12a. DECEDENrS USUAL OCCUPATION (Give /cInd 01
"""'fñs'tfüë{'~ Il1o. Do nor use reUrad.)
13c. CITY, TOWN, OR LOCATION
stewart
580-2211(3-03)
i
10. MARITAL STATUS - Married, N8Y9r
MarTlod, _, ~, (SpacIIy)
Married
13a. RESIDENCE - STATE
11. SURVIVING SPOUSE'S NAME
(II wife, give 1ui/1I18/den nom.)
Sandra Fay lamp
13b. COUNTY
19710 Felton Road
14. WAS DECEDENT OF HISPANIC ORIGIN
(Specify No or)i¡¡s . «yes, specify Cuban. Mexican, Puerto Rican. etc.)
o
IKI No
131. INSIDE CITY LIMITS 13g. YEARS AT PRESENT ADDRESS
1 2 1 2
o Yo. ΠNo 0 Under 5 IKI 5-9
15. RACE - Amarlcan Indian, Black, Whlla, ole,
(Spacify)
3 4
o 10-19 0 20 or more
18, DECEDENrS EDUCATION
(Specify only hlghe.t gred6 oomp/etad)
Rufus :b"auber
ElemontarylSacondory (0-12) Colloge (1-4 or 5+)
+2
o Ves Specify:
White
17. FATHER'S NAME (First, MIddle, L.a.')
M. Elliott
19b. MAILING ADDRESS (Street snd Number or Rural Route Number, City or Town, StBtS. Zip Codø)
lace Lane
24501 :
20<1. LOCATION (CUy or Town, Slalol
Columbia Missouri
22b. FUNERAL ESTABLISHMENT
LICENSE NUMBER
Memorial Funeral Home
1217 Bus. 70 W., Columbia Missouri
2005012238
23. PART I. Enter the diseases, injuries, r compllcallOO8 that caused the death. Do not enter the mode of dying, such as cardiac or respiratory BRest, shock. or heart failure.
Ust only one tause on each line. . I
IMMEDIATE CAUSE + .. Acute myocardlal lnfarction
(FIn.' dJBS8'. or DUE TO (OR AS A CONSEQUENCE OF)'
condIlion resulUng .
IndaBth) ( b, Severe arteriosclerotic disease
=1:~lrf I~, DUE TO (OR AS A CONSEQUENCE OF):
~~~~~n~~r1l18d1ato c. Chronic renal insufficiency
UNDERLYING CAUSE
(dl..... or Injury thaI DUE TO (OR AS A CONSEQUENCE OF):
initiated ..-enls resulting
in d..'h) LAST
PART II. Other significant condlUons contributing 10 death but nol resulting In the underlying cause given In Part I.
Approximate Interval Between
Onset and Death
Instant
Years
24. IF DECEASED WAS
FEMALE 10-49. WAS SHE
PREGNANT IN THE LAST
90 DAYS?
25., WAS AN AUTOPSY
PERFORMED?
25b. WERE AUTOPSY FINDINGS
AVAILABLE PRIOR TO
COMPLETION OF CAUSE OF
DEATH?
1
oVes
2
oNo
DUnk,
XI Ves
2
o No
1
rx Ves
2
o No
26. MANNER OF DEATH
14 Natural 0 Pending
o Accident Investigation
o Suicide 0 Could not be
o Homicide Determined
288, (Spec//y)
o CERTIFYING PHYSICIAN
MEDICAL EXAMINER/CORONER
27a, DATE OF INJURY
(Month, Day, liI.r)
27b. TIME OF 27c. INJURY AT WORK?
INJURY
27d. DESCRIBE HOW INJURY OCCURRED
M
1 2
oVaa 0 No 0 Unk,
27e. PLACE OF INJURY· AI homa, farm .trea~ faclory, ollic8
building, ale. (specify)
271. LOCATION (Street.nd Numbsr or Rurel Roul. Numbs" City or Town, 51810)
1/24/2007
28d, TIME OF DEATH
pronounced @
11 : 45AM
(Signature and Title) .. ~ ~. ~ (.Ð~\IL
28c. DATE SIGNED
(Month, D.y, lllar)
28b. To the best of my knowledge, death occurred at the time. dale and place and due to the causø(s} slated.
29a, NA¥ïAiD,ADDRESS OF CERTIFIER (PHYSICIAN, MEDlpAL EXAMINER OR CORONER) (7ÿpø or Print)
Wl lam W. Harlow, Sallne County Coroner
226 S. Odell, Marshall, MO 65340
29b. MO. LICENSE NUMBER 30. WAS CASE REFERRED TO MEDICAL EXAMINER/CORONER?
31. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
(7ÿpø or Prinl)
"
THIS is A CERTIFIED COpy OF A~I C '1IGINAL DOCUMENT
(Do nOÎ accupt if re¡;j'lOto~1 ap/;ed, or if seal imp, qss;on cannot be felt.)
THE REPRODUCTION OF THIS DOCUMENT IS PROHIBITED BY LAW (sec. 193,24j, 193.255, & 193,315 ilSMo 1994),
STATE OF MISSOURI } ¡: ,
ss I HEREBY CERTIFY that this is an exact reproduction of the certificate for the person named therein,"
records of the Bureau of Vital Records of the Missouri Department of Health and Senior Services. Witness my hand as ounty Registrar of Vital Stat
Department of Health and Senior Services this date of .
~.
....
MQ 580'1103 110,011
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