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STATE OF WYOMING )
)
COUNTY OF LINCOLN )
REC£I'IW ~?JlltK>14/;4:06(JM
RECEIVING # 931881
BOOK: 667 PAGE: 898
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
SS.
000898
AFFIDAVIT TERMINATING ESTATE
I, Jerry L. Wilson, being of lawful age and first duly sworn according to law, upon
my oath, depose and state:
1. That I am of adult age, a resident of 4371 S. 2900 W" Roy, Utah 84067,
and the Affiant herein,
2. That by virtue of the conveyance which is recorded in the office of the
County Clerk for Lincoln County, Wyoming, located at Kemmerer,
Wyoming in Book 619PR on page 702 is recorded a Warranty Deed. The
Warranty Deed, dated the 12th day of May, 2006 conveys unto Jerry L.
Wilson and Venna M. Wilson, husband and Wife as Tenants by the
Entireties with full rights of survivorship the following described
property, to-wit:
Beginning at a point on the west right of way of Turnerville-Grover Park
Road and being S 8ØEast, 696 feet from the ~ corner between Sections 14
and 15 in T33N R118W of the 6th P.M., Lincoln County, Wyoming and
running thence N 90oW, 320 feet; thence N 0°0' E, 200 feet; thence N 90"
0' E, 440 feet; thence meandering southwesterly along the west right of
way of Turnerville-Grover Park County Road back to point 1, the place
of beginning. Containing 1.75 acres, more or less. Including water rights
and improvements, including a 1/3 undivided interest in water pipeline on
the premises.
3. That said Venna M. Wilson died on the 20th day of April, 2007, and a
copy of the original certificate of death, certified to as true an correct by
public authority in which the original of said certificate is a matter of
record, is attached hereto as Exhibit "A".
4. That by reason of death of said Venna M. Wilson and by reason of 2-9-
102 W.S. (1980), the decedents interest and title in said conveyance has
terminated and title to the real property conveyed thereby has vested
absolutely in Jerry L. Wilson continuously since the death of the said
decedent.
FURT~NT SAYETH NOT.
Date~ ~;?
/
State of Wyoming )
)ss.
County of Lincoln )
The foregoing instrument was subscribed and sworn to me by Jerry L.
Wilson this ;)."Nl> day of August, 2007
Witness my hand and official seal.
~JI.~~
Notary Public
My Commission Expires:
-/6 - 07
RIA K. BYERS. NOTARY PUBLIC
County of .
Un coIn State ,of
M C Wyommg
y ommlsslon Expires Sept. 15, 2007
f&1'1/H
AFFIDAVIT FOR CORRECTIO~
This is a legal document. Complète in black ink and do not/alter.
ANY CHANGES MADE BELOW VOID THIS CERTIFICATE. A NEW CERTIFICATE MUST BE ISSUED TO VALIDATE CHANGES.
All vital records 'are registered as received. Corrections must be mad;} by affidavit. An item on the birth or death certificate may be corrected by
affidavit only once; a court order will be required for subsequent corrections.
There is no processing fee for affidavits registered within one year of the date of the event. After one year from the date of ~he event, there is a
fee for filing the affidavit which includes one replacement copy. Affidavits completed within 90 days of issuance may be given credit for monies
,previously paid. (Multiple 90pies may require an additional fee.)
'. PLEASE RETURN ALL COPIES WITH ONE~OMPLE¡:TED AFFIDAVIT WITHIN 90 DAYS FOR REPLACEMENT TO:
UTAH DEPT. OF HEALTH, OFFICE OF VITAL RECORDS AND STATISTICS, POBOX 141012,
SALT LAK~ CITY, UT 84114-1012
BIRTH CERTIFICATES
1. List the facts exactly as stated on the reverse side. Opposite each item, correct the information as it should have been stated at the time of the birth.
2. Who may sian the affidavit for corrections: If the person listed on the record is under 18, both parents listed on the record. If the person listed on the record i~
18 he/she mùst sign as one of the witnesses, unless--mentally incompetent or physically incapacitated. Parents or\ other older relatives are preferred witnesses
for the second signature. If no father is listed on the record, an'older{relative of the mother of legal age may sign. The signatures must be notarized.
3. The parent(s) may add or correct the surname from that listed on the record until the child's first birthday without proofs. The first, and/or middle name can be
corrected or added without proofs until the child's sixth birthday. /
4. If the child is under the age of six and there is no father listed on the record, the child's surname may be corrected to match the mother's maiden name without
documentation.
5. Minor correctTòns in spelling or parents' information may be corrected anytime. Some corrections may require documentary proof.
6. This affidavit cannot be used to add a father to or correct medical information on a birth certificate.
DEATH CERTIFICATES
1. If corrections to non medical information are not being made by the Funeral Home. the Informant MUST sign as a witness along with an older relative of the
decedent, onanother person who is knowledgeable of the facts.
2. The medical information (Cause of Death) may only be corrected by the certifying physician or the Medical Examiner.
"
LOCAL FILE NUMBER STATE FILE-NUMBER
NAME AS la. FIRST NAME :1b. MIDDLE NAME :lc. LAST NAME
, REPORTED ON ., I I
REVERSE 1 1
2a. FACTS EXACTLY AS STATED ON THE ORIGINAL RECORD 2b. CORRECT INFORMATION
( "
STATEMENT OF
CORRECTIONS
"
I
i
\ ,
3.
WHY IS CHANGE
NECESSARY?
4. \ '\
PROOFS USED TO
AMEND RECORD
I hereby certify, under penalty of perjury, that I have personal knowledge of the Subscribed & Sworn to before me this _day of 20_
above facts and that the information given is true and correct. Notary Public
5. SIGNATURE OF WITNESS My Commission e¡lreS
OATH OF FIRST
WITNESS 6. DATE SIGNED 17, AGE OF WITNESS lB. DAYTIME TELEPHONE /I OF WITNESS \
{MUST BE 18 I S
I . ( ).
OR OLDER) 9. ADDRESS OF WITNESS (Street. City. State. Zip) E \
A
10. RELATIONSHIP TO PERSON IN la: Self ParentlGuardian Spouse L
Funeral Director , Informant Other (Specify) \
\ I hereby certify. under penalty of perjury. that I have personal knowledge of the Subscribed & Sworn to before me this -,-- day of 20_
above facts and that the information given is true and correct. '.
Notary Public
11. SIGNATURE OF WITNESS My Commission ~xpires
I
OATH OF SECOND
WITNESS 12, DATE SIGNED \13. AGE OF WITNESS \14. DAYTIME TELEPHONE /I OF WITNESS
{MUST BE 18 ( ) S
OR OLDER) 15, ADDRESS OF WITNESS (Stre,et. City. State. Zip) , E .'
\ A
UDOH-OVRS 16. RELATIONSHIP TO PERSON IN la: Self ParentlGuarCtian Spouse L \
REV. 02/06 Funeral Director Informant Other (Specify) ,
o BIRTH
o DEATH
o STILLBIRTH
~
REÇ)ISTRARS USE ONLY: Number of Certificates Replaced: _ Initials: _ Date:_
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