HomeMy WebLinkAbout874077
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BOOK '~J:'U 'PR PAGE~1
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state of wyoming
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) 55.
&74077
RECEIVl::D
JNCOLN COUNTY GLERf{
01 JUN 22 ~J'IIO: 51
county of Lincoln
AFFIDAVIT OF SURVIVORSHIP JEANNE \\:)~\CNEn
I<EMMEnEr~. W','OMING
I, Anna May Miller, being of lawful age and duly sworn
according to law, upon my oath, depose and state:
That under the date of April 24, 1984, for valuable
consideration, ~eisure Valley, Inc., by deed of that date,
which deed was duly filed of record in the Office of the
"Lincoln County Clerk, on April 30, 1984, in Book 213 of
Photostatic Records on Page 180, conveyed to Harvey D.
Miller and Anna May Miller, husband and wife as joint
tenants, the following described property, to-wit:
T.Jot Forty-One (41) in star Valley Ranch Plat Three
(3) as platted and recorded in the official records of
Lincoln County, Wyoming
That by reason of said conveyance aforesaid, the said
Harvey D. Miller and Anna May Miller, Husband and Wife,
became the owners of the above described land, and title
thereto vested in them continuously from the date of
conveyance described in said deed to the date of death
of Harvey D. Miller, also known as Harvey Dwight Miller,
on the 18th day of June, 2000. That by reason of and upon
the death of Harvey D. Miller, title to the above described
real property vested absolutely in Affiant, Anna May Miller,
as surviving spouse.
Affiant avers and certifies that Harvey D. Miller,
also known as Harvey Dwight Miller, is the identical party
named with the Affiant in the aforementioned deeds 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 .;;[ ~ day of June, 2001.
-
~nd- ~afr~!d~-L.
An a May Mill r
subscribed and sworn
by Anna May Miller, this
to before me and in my presence,
'\)..
;f~= day of June, 2001.
WITNESS my hand and official seal.
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Not ry Public
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_83
STA~_;'OMING
DEPARF HEALTH
CERTIFICATE OF DEATH
O"'3Ii~il(_
1 6 .-}
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Wyoming
11. WAS DECEDENT EVEIlIN U.S, AIlMEO FOIlCES?
(Speelfy )a <H' nol
Yes
Count
o. MARRIED. NEVEIl MARRIED.
WIDOWED. DIVORCED (SpM:lfy 1
Married
STATE FllE NUMBeR
2. SEX 3, DATE OF DEATM (Mo-, o.Y. It.)
TYPE
OR PRINT
IN
PERMANENT
"'-"'K
INK
FOR
INSTRUCl10NS
SEE
HANDBOOK
LOCAL FILE NUMBER
I. DECEDENT-NAME FIRST
MIDOLE
520-22-2502
So. AQE-Laa' elf""'..,
fY__J
73
Male June 18, 2000
e. DATE OF elffiH lMo.. Do,. Yr.)
HARVEY
DWIGHT
.... S()ClAL SECURITY NUMeE~
February 26, 1,927
70. PLACE OF OE"TH (Cl>oCk 0I>tt "",,)
1-t05P1T"'-' 0 Inpall",,' ~ ER I OU....Uon, 0 DO" Qll:!fB: 0 Nur""" Homo 0 R..Ideno.
7b. FACIUTV NAME (N _ lns~lulJon. gJ"" ._ _ runborl
7d. COUNTY OF DE..TH
Memorial Has ita! of Sweetwater
8. STATE OF BIRTH 1<< "'" In U.S.A.. "...". Oouriry)
Sweetwater
Anna May Mills
Railroad
12a. USUAL OCCUMTION {G.... k1m1 01 warlc d~ (llIltIg mos'
ol _In" mo. _ <<fOtherl)
Retired Telegrapher
12b. KINO OF BUSINESS OIlINOIJSTRY
130. RESIDENCE - STATE
13b, COUNTY
130. CITY, lOWN Oil LOC..TION
Wyoming
13<0. INSIDE CITY UMITS?
(Spodly ... or nol
Sweetwater Rock Springs
I.. WAS DECEDENT OF HISP..NIC OIlIGlN?
(llpooll, no <H' ,.. - II "'. _oily
Cuban. Mexk:.an. ~no Rk.an. Etc.~
"I" Street
IS, IlACE-Amerlcon Indian.
91001<. WI>.... E"'.
I St>eclly 1
Yes
17. FATHER'S NMlE
rnl
N.Xi Yo. 0 (~Ilyl
Middle L>o\
White
f 6. oro~NT'S EDlJCA7ION
I_Iy 0<"Iy hIg"'" """. oarp/oIorI J
ElemenlOrilSecordory (0-12 College 11-.0< HI
1 2
18. MOTHER'S NMlE
First
Mldd'"
Ma~" Sw""me
Floyd
10.. INFORMANT-NAME mP'O <H' Printl
Everett
Miller
Anne Evelyn
lOb. RELATIONSHIP TO OECEOENT
Lindenmeier
Mrs. Anna May Miller
190. MAIUNG ADDRESS STIlEeT OR R.F,O. NU"BeR
Wife
CITY OR TOWN
ST"TE
ZIP CODE
514 "I" Street
Rock Springs, Wyoming
20<:. q:METERY OR CREM..TORY -NAME
Rest Haven Memorial
82901
Home
CITY OR TOWN
ST..TE
June
1;>-
i1!
i~
M ~~
tl!8
-h
Coroner
.110UR OF DE"1I1
June 19, 2000
12:53 A
M
22d. N....E OF ..TTENDlNG PflYSICIAN IF OTHEIl THAN CEflTlFIER 17_ or F'mfl
23d. PIlONOUNCEO DEAD lMo-. 0.,. Yr.1
23<0. PRONOUNcED OE..D IHo..-I
June 18, 2000
12:53 A M
2.. N""'E AND MlORES$ OF CERTIFIER (PHYSlC,..N OR COAONER)~ or Pm/.I
Francis 1. Hatch, M.D., Memorial Hospital of Sweetwater County, Rock Springs. Wyoming 82901
25b. DATE RECEIVED BY IlEGISTAAR lMo.. (loY. Yr.)
June 19, 2000
"- Coronary Sclerotic Heart Disease
Due TO (OR ..s A CONSEQUENCE OFI:
~MJII\A'.
f It1te~ 6elwBtm
10000' .nd DooI~.
I
: Minutes
I
I
I
I Days
I
I
I
I Years
I
0. Cardiac Tamponade
DUE TO (OR ..s " CONSEQUENCE OF):
Sequen,""1y U., "on,III1,.,..
I ""Y. I..dlno '0 Immerllo..
eewo_ Entet UNDERLYING
CAIJSE (01...... or Injury
tIla. InltLllted 8-...,(11.
,....lItlQ In dea'''') ~
~. Ruptured Myocardial Infarct
DUE m (OR M. A CONSEOUENCE OF):
d.
MFrf U. OTHER S~NIRCANT CONDlllOHS-CondUlona cc;mlrlbullnQ to da.lh bl.A I\Ot reIa'ed to telllUSO GNen 10 PART I.
Na1ur"
0-
IfN'II!I'::'tion
30.0. DATE OF INJURY
l-.or. 0.,. -I
30~. TI"E OF
INJURY
300. INJUIlY "T WORK1
ISpedly ,.. or no,
21. ..IJTOPSY (SP<<JIy 28. WAS CM.E REFERRED TO CORONER
.... or "" ISpodfy .... 0< ""I
Yes Yes
3Od. OESCRI8E HOW "'.mRY OCCUIlIlED
Diabetes Mellitus
,g. 1.1A1mER OF DEIITH
VR 2-89
B/97 15M
-
o Cc<J1d no< be
001....._
M
300. PLACE OF INJURY- "1_. 'arm. .....,. ,,,,,'0<,.
aI""" bulldl"". "0, ISpo<:/fy I
3D'. LOCAllON (S......, .nd ...._ or flur" RoulO Number. City 0< T"""'. 5....1
--..
Homlol<lo
DATE ISSUED June 20, 2000
THIS IS TO CERTIFY THAT this is a true correct conformed reproduction of the original
copy of the death certificate completed by the V ASE FUNERAL HOME and sub~tted .
to the VITAL RECORDS SERVICES, Wyoming Department of Health and SOCIal ServIces,
Division of Health and Medical Services at Cheyenne, Wyoming.
~~~
VAS.E FUNERAL HOME
154 Elk Street
Rock Springs, Wyoming 82901
STATE OF WYOMING) s
COUNTY OF SWEETWATER) s
Subscribed and sworn to before me a Notary Public
this 20th day of June 2000
1 -=- " S-L
My commission expires on
April 21, 2002
.......II1II