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Affidavit of Survivorship
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I, Billie J. Davidson, being of lawful age and duly sworn according to law,
upon my oath, depose and state:
That under the date of March 7, 1997, for valuable consideration, Leisure Valley,
Inc., by deed of that date, which deed was duly filed of record in the Office of the
Lincoln County Clerk, on May 5, 1997, in Book 396PR, Page 845, conveyed to Robert C.
Davidson and Billie 1. Davidson, as joint tenants, the following described land, to-wit:
Star Valley Ranch RV Park Plat 1 Lot 133 as platted and recorded in the official records
of Lincoln County, Wyoming
That by reason of said conveyance aforesaid, the said to Robert C. Davidson
and Billie J. Davidson, as joint tenants, became the owners of said real property, and
title thereto vested in them continuously from the date of said conveyance to the
date of death of Robert C. Davidson, on the 28th day of March, 2004. That by
reason of and upon the death of Robert C. Davidson, title to the above described
real property vested absolutely in Billie J. Davidson, as surviving spouse.
Affiant avers and certifies that Robert C. Davidson is the identical party
named with Billie J. Davidson in the aforementioned deed, whose death
terminated his interest, title and estate in said real property; and Affiant attaches
hereto and makes a part of this affidavit, a copy of the Official Certificate of Death
of said decedent, duly certified by the public authority in which said death
certificate is a matter of record.
Dated this~/D.. day of ~ ' 2007.
þd~ Q, y~___
, Billie 1. Davidson
State of a~'r)
County of Uw ð'J \ "'--
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Subscribed and sworn to before me, a notary publi~ and for said County
and State, by Billie J. Davidson, this '2..û""^dayof J (:J ,2007.
WITNESS my hand and official seal.
NANCY J. BROWN - NOTARY PUBLIC
COUNTY OF . STATE OF
LINCOLN - WYOMING
MY COMMISSION EXPIRES J2J ().5lðð
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My Commission Expires:
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RECEIVED 7/23/2007 at 2:37 PM
RECEIVING # 931532
BOOK: 666 PAGE: 617
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
This Docum.nt Is being recorded by
Rocky Mountain Title Insurance Agency
of Lincoln County as a COURTESY only
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. DIA'" WAS
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'HNt NATUiltAL
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sa.. TH'
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STATE OF IDAliO
IDAHO DEPARTMENT OF HEALTH AND WELFARE
--"---··-""··SUREAU OF HEALTH POLICY AND VITAL STATISTICS
.ATI Fn.E. IUTATI REGIST......, / Slale arld.h. .
CERTIFICATE OF DEATH "ATEFILENO,
fM~~":'':uOC:=:A~I=:='~:-:-'':''':.':':U::=::::'::.~I::::~·· lOClI Reo. Na.
0006j.8
180 #7
" 1. DECED!HTS LEOAL NAME (lndUde AKA's H any. (First. Middle.ln" SuMxl
3. SOCIAL SECURITY NUMBER
73 (Y...., May 25, 1930
-5 la. RE ICIHC! 6 ATIOR
..
ª Idaho
~ fd. STREET AND NUMB R
>
~ 730 North' Woodruff
~ ~ t. RITALSTATUSATT1MEO DIATH
~ ~ !X~ a Mo~otI. buI'O "'~ 0 _ a Di_.. a Ne.eure"'" a Unk.....
U> ,
t= œ 10.:~~~H .11...FATHElrSNAME(First"Middl..Lasl. mx)
~ 1! FORCEO? Robert Leon Davidson
::æ ; 0 v.. 1:11. MOTHER'S MAlDEH HAIotI! ( Irsl, Middle. L.st, Sulnx)
~ IX... R¿ì:h Archibald Leatham
S 13a.INF RMAHT'S NAME CTWM or prttIlJ 13b. RELATIONSHIP TO DECEDENT
.! , .
g Billie Davidson Wife
8' " ,.t. METHOD OF DtSPOSrTION 15. PLACE OF DlSPOSmON (NM18 and ~H 01 cemelery.
iX_ C CtenotIan· _......0I_)
0....._ OEn_ Annis-Little Butte Cemetery
~~:""ho Rigby, Idaho
" 1fa. SfQHATU OR PER ON ACTING UC
RAlel[t.--I..dJ~ho
7c. CITY OR TOWN
Billie Joan Wood
ftb. BIRTHPLACE (Shll.. Terrllory, or ForeIgn Coonlry
12b. BIRTHfJJl~sllle. TerTllory. or Foreign Country
13c. MAIUNG ADDRESS (SI,eet 1~~rrtJer. CUy, Slale, Zip Code'
83401
730 North Woodruff Idaho FaJ,.l.I!-,_J]:)
. 11. NAME AHD ~ ADDRESS OF FUNERAL FACIUTV
Wood Funeral Home
273 N. Ridge - PO Box 51434
40~
II. WAS CORONER CONTACTED?
o Ves XJ No
PLACE OF DEATH 18.22
* "8. IF DEATH OCCURRED IN A HOS AI.: ,* lib. IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
. EAIOuIpa..,.. ,0 DOA 1.0 Ho.pke facility ,a Nursing homeI\.ono lenn c.re fadllly .0 Deoecfionfs home rO OIher (SPec;lfy)
( DIll laollly. give str... and fU1"Ger1 . 2'. CITY, TOWN, OR La ATION OF DEATH. AND liP CODE . U, COUNTY OF DEATH
March 28, 2004
Idaho Falls Bonneville
25. DATE PRONOUNC~D DEAD (MoiOavlYrJ ( pell monlh) 21. TIME PRONOUNCED DEAD
(2'h,) March 28, 2004
27. CAuse OF DEATH
PAR-r I. En....lh. ~ - diseases. '"Iuri... or compIiQI1on.·-INtI dtredty C8UHd Ihe death. DO NOT enllllermNl evenl. ~.. urdlac
",.... ,........cwy an>ell. Of wenIria.IIlt ~ wilhoul Ihovwtng Ihe ellolooy. DO NOT A88REVlÞ.TEr Enler only one cause on . line:
1304
I AØØfoxlnwle Inler4l:
J OMellD De.'" .
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reluIt6ng In dulhJ '.. DUlTO,...__.__ol):
Sequonttolly'" candI...... b. PTs. "11 0
il.ny.IUdIng 10 !he CMIM DUe.!9J-"_. _____ eI'þ:
1..'otIon..... En...... .. 'Po.:a .. ~ ì ;. V <..r-t t-r; .......\ f'>-
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~ ::::.~::~d:~- d. ..-1../ I CJ Jot":; b
o PAR \1. let' oIh... lJamkMl alndtllOl,. ttW'IlribuIlna to dnlh bUl not ,..wllng In Ihe undtf1ytng Quse gtven In Part
id \ -'
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u. N II. Dto TO AC 0
¡:: ,... CONTRIIIUT'e TO DeATH?
ffi ~,KY.. 0 "'1Ib.1IIy
U~ a... DUnIo_
-i U.DATI!OFIHJURY(~,)
E I.... .-hl " ..
<3
Þr/I.t'-"1 JI1-f\-o./lr
2Ia. WAS AH AUTOPSY ;2Ib. WE'RE AUTOPSV FINDINGS
PER'ORMED? I AYAfLABLE TO COMPLETE
: THI! CAUSE OF DEATH?
: tJV.. Otto
av.. ~
o No( pregnBnt bur Pfeonant "'3 daVl. 31. MANN A 0 DIA
10 1 year befDl'e dlll.1h , ~',,"I 0 Homdde
o UnltnoMt If' Pll.onant WI~" h"... 0 Accidet11 0 Pendinvlnvnllo-tlon
)'War ' 0 Suicide 0 Could nol b. delenftned
.,... PlACE OF INJURY (Oeced..,,·. home. l.uJ\ sllIr:el. ~oll~nÀ.;lon slle, 3S.INJIJRY AT WORK7
nursing home. .......nI. fornl. lle.J
(l''''1
DYes
o No
OI (T.... 01 County
Z", CÐdo
Sir... and ~ or locdatl" AP8t1met1l Nurre.,
37. D RI8E HOW INJURY OCCURRED. IF TRANSPORTATtoN INJ.URY, STATE TH TYPE(S) 0 VEHICLECSIINYOLV£D (AuI~bHe. pickup. mofDt'C)'dtl. A . blcyde. elc.)
SPECIFY WHICH VEHIClE. DECEDENT OCCUPIED..." _abte
·0
.; '"..
TRANSPORTATION .3'8. WAS DECEDENT:
INJURY ONLY I 0 Pede..... 0 0Ih0r
o Unknown
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-tOb. DATE! SIGNED
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~tb. DAT~ ~GNED ?,ü.' /
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This Is a true and öòrreõÙeprodùçtfon 01 the doçument olllçlally registered and plaçed
on IlIe with the IDAHO;BUREAU;OF HEALTH POLICY AND VITAL STATISTICS. '
:::~~I~~~~~_, ?J:z:e
displaying state seal and signature ol·tI1e·,RegIBtrar,·· STATE REGISTRAR
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