HomeMy WebLinkAbout876361THE STATE OF WYOMING
COUNTY OF 849
ss
1. On the 2Y day of a4,u -v-ur
876361
RE 0E1VED
l_INC- ai_.P! COUNTY CLERK
0 f "!i^
00K 4 PAGE 5 8
rF: Y.1. r ?-1
t;'
AFFIDAVIT OF SURVIVORSHIP J E A
MIKE J. BRENT, being first duly sworn upon her oath, deposes and states as follows:
fit', my wife, BETTY BRENT, died, as is
evidenced by the official certificate of death attached hereto and incorporated herein by this
reference.
2. At the time of her death my wife jointly held an interest in 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 #44 of the Spring Canyon Ranches Subdivision the same as appears of
record on the official map of plat thereof filed ,in the Office of the County Clerk
and Ex- Officio Register of Deeds for Lincoln County, Wyoming.
TOGETHER WITH all improvements, rights of way buildings, and all things
appertaining thereto.
3. Our interest in said real property was subject to an Agreement for Warranty Deed
dated June 4, 1987, and recorded in the Office of the Lincoln County Clerk and Ex- Officio
Register of Deeds on January 5, 1988, in Book 258PR at Page 271, wherein MIKE J. BRENT
and BETTY BRENT, husband and wife, were listed as purchasers.
4. By reason of my wife's death, I am entitled to sole interest, if any, in the above
mentioned real property.
DATED this
My Commission Expires:
2
day of /C.�. 2001.
MIKE J. BREN21
BSCRIBED AND SWORN to and acknowledged before me this /7 of
2001, by MIKE j. BRENT.
WITNESS my hand and official seal.
Notary Public
Robert S. Wood Notary Public
County of
Lincoln
State of
WYoming
My Commission Expires__?
C59
i t 1
DECEDENT
5 i co 112-
i
2_
1
ID
1. NAME OF DECEDENT FIRST,
B
4. DATE OF FIIRTH/NoDesyy.
Jul 1.
6 1952
M
....:....,..,4 .,'•Y:13
5,.A Of:0 24
y..1
LAST
Minutes
2.
6. BIRTHPLACE
Kemmerer
SEX
ZIAL.
(City Slate
8b. NAME OF HOSPITAL,
t NUMHEFI
3a. DATE OF DEATH (Mo. Day Yr.)
O o o
or Foreign Country) 7.
man 520-60-6
NURSING HOME OR OTHER
b. TIME OF DEATH (24h look)
OCIAL SECURITY NUMBER
2
FACILITY (go/I/side a facility
HOSPITAL
t. :i nisq.: g w..
1. Inpatient 02.ER(Outgatient 1,130A• x 3 Herer1 L.-I 6 :1 3 e§idonco 0 7. Other
gIve street address of location)
DS Hospital
8c. CITY, TOWN OR Locoptsig.DP„Arg;;;X
,,Rnt10,..,-
9. SURVIVING SPOUSE (it 00o9 ea maiden name)
11
1.1 m
?w
:1
xi OM
3" P
PA
8
PARENTS
'DOR
INFORMANT
MAI •IN 859 g
t
DISPOSITION
90) SP
22. SIGNATURE OF FUNERAL' VIDp.'c
1F x
4.ICENSEE NUMBER
11519
24. FUNERAL HOME (N ss ame, addre and license number)
Crandall Funeral Home
CERTIFIER
25. DATE DECE ED WAS LAST:
ATIENDE BY CERPFYIND FHiSIDIA
I aq C ti
43 /200 elIalatI*. Was death reported to M.E.? 02 yes Ja No
tAdeir fegorted. M.E. Case No
P.O. Box 0644
DAY YEAR
Evanston, Wyoming 82931.
27a. CE IFIER
;••A i7"/;;%:
1. CERTIFYING P)1YSICIA14' i Vne sip death
occurred at the lime, date, and place, and due 10 the cause(s) and manner as stated.
0 2. MFDICAI A_ANF41*FNEGI'VEM F A On the basis Of examination
and/or investigation, in my opinion, death occurred at the time,
19 p P, 04§4f !hkPWii.t 15i104gt/YY5000.
gift ii N-
27c. LICENSE NUMBER
/r1882--/ 2- oi
27d. DATE SIGNED (Mo., Day, 11,.)
e.
20.. D ADDRESS OF pERSC75;y1(FIDPARTIFIED r2F:DEATH (27BM 3 1)(Tpe
a '1.'.'"?:.5'
h' a9 Awe: ,so .S;g/,/4,1
777 al: ity/a3
REGISTRAR
51\
CAUSE OF
DEATH
3 4.
M C‘i
29, REGISTRAR'S SIGNATURE r 5- -'7' 1ZXM'''
31. PART I ENTER THESDISEASEIN ,,7 0,1,10di $j )440/NWED THE DEATH.
OR RESPIRATORY ARREST;;SHOC
POO OJECALISE ON
IMMEDIATE CAUSE (Final
&sem Of condition 4:
de
300. DATE REGISTRAR NOTIFIED OF DEATH (Mo.,Day,Yr.) 30b. DATE FILED (Mo., Day. Yr.)
2. 96 Jan. 31 1996
DO NOT ENTER 111E MODE OF DYING, SUCH AS CARDIAC Approximate Interval
EACH UNE. Between Onset and
Death.
r
resulting in ath)
,L A Til P -1 1 0U P 59').
b r 44 4 /•)4., t /-c c
4
Us.l.iy, .44 ;;4‘ 1 S
Sequentially list
conellions I,.:- I d i tt 0 e(O01 1 4 6 0igtait0;16 55 ri:
If any, feeding t. imM0 4 t 'Al.
CAUSE isease orinu h.., "t t.
(/01 -)-4 2--4
Initiated
that
events resultted CV 4 Atod0644,00
in death LAST
PART I). Other SigniIfaarlICondi8OnlContribelf 14# 1
52^ the under 61 '0' P 4-q
e.. 4.--
32.2)) YOUR OPINION. TOBACCO USE BY THE DECEDENT
0 1 i probably contributed to Um cause of death. 05 NON-USER
o able underlying cause of death.
„3. Ditinot contribute to the cause of death. D 6 UNK NOWN
Pekrtown In relation to the cause Id eath. IF USER
330. WAS AN
AUTOPSY
PREFORMED?
n
15::
335. WERE AUTOPSY
FINDINGS AVNLABLE
PRIOR TO COMPLETION
CAUSE OF DEA
U 1. Yes gvi. No
,..,..0.;?;:.
,.,4
',.---4--.1.. 6, 4 ••;"%4.
MA 014 07 DEATH
1:. Natural El Z Maiden!
4E'$) fN RV
356. TIME OF INJURY
(24 Hour clock)
35u. INJURY AT WORK?
es
0 1Y 02 No
350. PLACE OF INJURY Al home, farm, 5000), factory.
off ce, building,etc. (Specify)
DI sok ido y 4. Hmiqicle,
m, 6,I
0 5. Undetermined u
11in/tired Investigation
Accidentally
5. 3:2 098V Wet: a 1,414 nurpbk iih Or town. county and Vale.)
:„'J.',Y.;,;',,4'
351. If motor vehicle accident specifilf decedent was
driver, passenger or pedest rian.
3 9- DE,SCR(gifi 14 xy, k pcctmEci 'lento,: sequence of events which resulted in injury, NATURE OF INJURY SHOULD BE ENTERED IN ITEM 31)
i,
WARNING ILLEGAL TO biikicATE THis COPY FOR OFFICIAL PURPOSES.
nalikM p mvntr ANY ALTERATION OR ERASU Vs IDS TI HS CERTIFICATION. c
This is to certify that this is a true copy of thOettifi
underauthority of section 26-2-22 ,pf, .the:iff4b:Af*
Abeess Inlennation en
tles Item is limited ender
the Vilal Stalacs
and R0100
LOCAL FILE NUMBER
DEPARTMENT OF HEALTH
OrIFICATE OF DEATH
finIhre office. This certified copy is issued
4p5s.As Amended.
0 G 0
143 9 6 0 0 0 8 58