HomeMy WebLinkAbout876363STATE OF WYOMING
ss.
COUNTY OF TETON
'13 ;3OK474PIc PAGE 0 G
Patricia A. Jones, being of lawful age and being first duly sworn upon oath according
to law, deposes and states:
1. That she is the surviving spouse of Richard P. Jones.
2. That affiant and Richard P. Jones, as husband and wife, were the owners of real
property located in Lincoln County, Wyoming, more particularly described as Lot 224,
Lakeview Estates Subdivision, Alpine, Wyoming, as filed and platted in the Office of County
Clerk of Lincoln County, Wyoming.
3. That affiant and Richard P. Jones acquired title to the above described. property
by a Warranty Deed recorded on September 15, 1982 in Book 191 PR at page 737 in the
Office of County Clerk of Lincoln County, Wyoming.
4. That affiant does hereby certify under oath to the death of Richard P.
who was a co -owner of the above described real property with affiant as a tenant by the
entireties. The death of Richard P. Jones terminated his interest as a tenant by the
entireties. Attached hereto is a copy of the official death certificate of Richard P. Jones.
5. That this Affidavit of Survivorship is made in compliance with the provisions of
Section 2 -9 -102 of the Statutes of the State of Wyoming.
Subscribed to and sworn before me this 615 day of Sef renrlage-
2001.
Dated this 541, day of q
Witness my hand and official seal.
AFFIDAVIT OF SURVIVORSHIP
My Commission Expires: 3- 1b -apos
876363
Notary Publ
2001.
RECEIVED
LINCOLN COUNTY Y CLERK
Yl (,A 3
K t 0 Iv't 141 ERER,
RELEASED
SCANNED
e t hLLJ O
Patricia A. Jones
SANDY TOLAND NOTARY PUBUC
County of State of
Teton C Wyoming
My Commission Expires 3-16 -2005
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DECEDENT
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c a`ri_e�a: Y�Y
INFORMANT
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TYPE
OR PRINT
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FOR
INSTRUCTIONS
SEE
HANDBOOK
CAUSE
OF DEATH
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VR 2 -89
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13a. RESIDENCE STATE
13e. INSIDE CITY LIMITS?
(Specify yes or no)
yes
LOCAL FILE NUMBER 3.1
1. DECEDENT -NAME FIRST
Richard
4. SOCIAL SECURITY NUMBER
521 -32 -5831
7e. PLACE OF DEATH (Check only one)
8. STATE OF BIRTH (U not In USA, name country)
Colorado
11. WAS DECEDENT EVER IN U.S. ARMED FORCES')
(Specify yes or no)
no
Wyoming
17. FATHER'S NAME Fist
isza
Oliver Preston Jones
190. INFORMANT -NAME (Type or Print)
Patricia Jones
100. MAILING ADDRESS STREET OR RFD. NUMBER
P.O. Box 1485
20a. Burial. Cremation, Removal
from Stele, Other (Spoclly)
burial
210. FNNER L SERVICE LICENSEE
As
e
220. To e st my,,���.'...tryIIIrrrr
to the caose(0)
(Signature and WO
s
5
22d. NAME 0 ATTENDIN
y= g
2210 DATE SIGN -r (Mo.
STATE OF WYOMING
Preston
13b. COUNTY
MIDDLE
Teton Jackson,
14. WAS DECEDENT OF HISPANIC ORIGIN?
(Specify no or yea if yea, specify
Cuban, Mexican, Puerto Rican, Eta.) an
No t 7 Yes Speciy) 1
20b. DATE (Ma, Day, Yr.)
r men Acting
e, •e. h
6e. AGE -Last Birthday
(Years)
67
Printer
Middle Last
Number 21b. NAME OF FACILITY
24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER)(Type or Print);
Dr. 4) (0.44 t C :4T
26a. REGISTRAR
Sequentially list conditions,
it any, leading to immediate
cause. Enter UNDERLYING
CAUSE (Disease or [NM
that Initiated events
resulting N death) LAST
PART 5, OTHER SIGNIF
29. MANNE
Natural
Accident
Suicide
Homicide
F DEATH
31879
Pending
Investigation
'Could not be
Determined
DEPARTMENT OF HEALTH
DUE TO (OR AS A CONSEQUENCE OF):
:a s✓.°,�° hh A P TI N DF3„
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
LAST
Jones
56. UNDER 1 YEAR
Months Days
off BPITAL• oTHER:
Inpatient ER /Outpatient DOA Nu rsing Home Residence Other (Specify)
7b. FACILITY NAME (II not /nsEWEon, give street and number) 7e. CITY, TOWN, OR LOCATION OF DEATH
St. John's Hospital and Living Center, Jackson, Wyoming
B. MARRIED, NEVER MARRIED,
m Wi (Specif
12a. USUAL OCCUPATION. (Give kif xak dar durkig most
give Ile, o awn 11 reEnd)
130. CITY, TOWN OR LOCATION
Wyoming 325 W. -Kelly
16. RKCE- American Indian„ 16. DECEDENT'S EDUCATION
Blaooc,'Whlte, Etc.
_edr.. only .,_h_. grade completed)
(Specify)
CRY OR TOWN
Jackson,
White
20c. CEMETERY OR CREMATORY -NAME
(Signature) N! I a6.
PART 1. Enter the diseases, Inhales, or complications that caused death. Do not enter the mode of dy each
28. or respiratory arrest, shock, or heart failure. Uel oMy one cause on each lire.
Hours
May 28 1997 Aspen Hill Cemetery
10. SURVIVING SPOUSE (II wile, give maiden name)
Patricia Aline Stl
18. MOTHER'S NAME First Midd,a
Patricia Aline
MABLE
Wyoming
DISPOSITION
CERTIFIER
479 Valley Mortuary 119 170 •Bast Broadwa Jackson
22a ti R OF DEATH
2 7 f •M
PHYSICIAN IFL3THER THAN CERTIFIER (Type or Print)
/Am 7 -,oil feet meg5tik l
25b. DATE RECEIVED BY REGISTRAR (Ma, Day, 20)
23x. Or the basis of examination and /or Investigation, n my opl •n death 000000
at the time, data and place and due to the cause(s) staled.
(Signature end Ede)
8s 23d. PRONOUNCED DEAD (Ma, Day, Yr.)
IMMEDIATE CAUSE (Final /J
disease death)
V /J 1`///� �•n A- resulting In death) s1 a �i I� re�-C G r.i4 ...t DUE TO (OR AS A CONSEO /j EE OFL 4�7 /j
DUE TO (OR AS A CONSEQUENCE OF):
a
CONDITIONS Conditions co ¢00th but not related to cause given In PART L
300. DATE OF INJURY 306. TIME OF
(Month, Day, V') INJURY
M
30e. PLACE OF INJURY -Al home, farm, street, factory
office building, Mo. (SpeciN)i
This is a true and exact reproduction of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.
tt
DATE ISSUED:
30c. INJURY Al" WORK?
(Specify yes or no)
STATE
2. SE%
M
5c. UNDER 1 DAY
Minutes
130 STREET AND NUMBER
18b. RELATIONSHIP TO DECEDENT
Number
b. DATE SIGNED (Mo, Doy,' Yr.)
STATE FILE NUMBER
3. DATE OF DEATH (Ma, Day, 1t)
May 24 1997
6. DATE OF BIRTH (Mo., Day, Yr.)
February 13 1930
125.19513 OF BUSINESS OR INDUSTRY
Printing'
Elomentory' /Secondary (0 -12) College (1 -4 or 5
ZIP CAGE
83001
20d. LOCATION CRY OR TOWN STATE
Jackson, Wyoming
210 ADDRESS OF FACWTV
ors e.7 -97
27. AUTOPSY (Specify 28. WAS CASE REFERRED TO CORONER
yes or rid) (Specify yes Or no)
yes no
063
91 -01492
300. DESCRIBE HOW INJURY OCCURRED
Lucinda McCaffrey
Deputy State Registrar
This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar.
11
7d. COUNTY OF DEATH
Teton
Malden Surname
Ctranh GARTLAND
23c. HOUR OF DEATH
23e. PRONOUNCED DEAD (Hour)
M
r Approximate
!Interval Between
'Onset and Death.
M
j301. LOCATION (Street and Number or Rural Route Number, City or Town, State)
I
NAN