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My Commission expires:
_IDJRSCRIBED, SWORN TO, AND ACKNOWLEDGED before me this /f T// day of
--V'iA.'i.- ,2001, by MARY R. HARRIS.
Witness my hand and official seal.
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MARYR.H S ......~
, 2001.
~
DATED this ~ day of
4. This Affidavit is filed for the purpose of establishing the fact of the death of said ALBERT J.
HARRIS, who was the owner with MARY R. HARRIS of an estate by the entireties in the above-
described property, and to make an official record on the termination ofthe interests of ALBERT J.
HARRIS in and to said property and the vesting of the same in MARY R. HARRIS, his surviving
spouse, whose address is 48856 Oak Arbor Court, Shelby Township, Michigan 48317, all pursuant to
the provisions ofW.S. ~ 2-9-102.
Township 24 North, Range 114 West ofthe 6th P.M.,
Sec. 3: Lots 10 and 11
4. W-01902
Township 24 North, Range 114 West ofthe 6th P.M.,
Resurvey Tract 50: West 3/4
Resurvey Tract 55: All
Resurvey Tract 49: West 40 acres
Township 24 North, Range 114 West ofthe 6th P.M.,
Sec. 3: L 12, 13, EV4 of Tract 50
2. Arnold A.
Larsen,
et ux (Pat.)
3. Edgar F.
Herschler,
et ux (Pat.)
Township 24 North, Range 114 West ofthe 6th P.M.,
Sec. 2: Part of Resurvey Tract 48, originally
SWV4SWV4;
Resurvey Tract 46B, originally SEV4SWV4;
L-16, 39.10 ac; L-17, 5.71 ac; L-18, 6.48 ac
L-16, 39.10 ac; L-17, 5.71 ac; L-18, 6.48 ac
Sec. 3: Part of Resurvey Tract 48, originally E~SEV4, SEV4NEV4;
The most easterly V4 of Resurvey Tract 50, originally SWV4NEV4;
The most easterly 80 acre parcel of Resurvey Tract 49, originally
W~SEV4;
L-12, 22.51 ac; L-13, 20.35 ac; L-14, 17.84 ac; L-18, 17.84 ac
Sec. 10: Part ofthe most westerly 2/3 of Resurvey Tract 45, originally
NEV4NEV4
Sec. 11: Part of the most westerly 2/3 of Resurvey Tract 45, originally
NWV4NWV4
1. Arnold A.
Larsen,
et ux (Pat.)
DESCRIPTION IN LINCQLNCQUNIY. WYOMING
LEASE NO.
1. Affiant is the surviving spouse and the surviving tenant of a tenancy by the entireties with
respect to ALBERT J. HARRIS, deceased, and, therefore, has an interest in the mineral property which
is the subject matter of this Affidavit.
2. Affiant states that ALBERT J. HARRIS died on May 30,2001, in Oakland County,
Michigan, the facts of said death more fully appearing on the duly certified Certificate of Death attached
hereto and by this reference incorporated herein.
3. During the marriage of ALBERT J. HARRIS and his spouse, MARY R. HARRIS, Affiant
herein, said ALBERT J. HARRIS and Affiant acquired as tenants by the entirety certain mineral
property by Mineral Quitclaim Deed from Albert J. Harris, which Mineral Quitclaim Deed was
recorded in the office ofthe County Clerk of Lincoln County, Wyoming, on July 12, 2000, in Book 448,
Page 465, which property is more particularly described as follows:
MARY R. HARRIS, being first duly sworn, states as follows:
RECEIVED
UNCOL,N COUNTY CLERK
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!(EMMEi'?CF:. \VYOMING
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BOOK_..:j,t~::'._PR PAGE 6 1 9
AFFIDAVIT OF SURVIVORSHIP
874229
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COUNTY OF /7/./1 t! :.'1'1 (f
STATE OF MICHIGAN
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STATE OF MICHIGAN
OEPARIMENI OF COMMUNIIY HEALIH
STATE FILE NUMBER
CERTIFICATE OF DEATH
1493393
1 DECEDENT'S NAME (Fus', Middle. Lasl)
ALBERT
HARRIS
3 OAT[ OF Of A TH (Month Day. Ye.J')
May 30, 2001
J.
4a AGE - Las! BIrthday
(Years)
(Month, D..y, Ye.r)
59
4c UNDER 1 DAY
HOURS I MINUTES
I
7. LOCATION OF DEATH (Enter plac. allicially pronounced dead In 7a, 7b. 7c.)
HOSPITAL OR OTHER INSTITUTION ~ Name (fI not In .,ther, BIV' SIr." ,nd numb,,)
CITY. VILLAGE, OR TOWNSHIP OF DEATH
William Beaumont
8 SOCIAL SECURITY NUMBER
ital - Tro
Troy
98. USUAL qCCUPATION (Give kind 0' work don. durin, most of 9b BUSINESS OR INDUSTRY
workln' Ide. Do not use retired)
Quality Control Inspector Automotive
362-38-7301
lOa CURRENT RESJDENCE: - lOb COUNTY
STATE
lOc. LOCALITY (Ch'ck on, bcn Ind sPfCify)
o INSIDE CITY DR VILLAGE Of
o TWP, Of Pontiac
lOd STREET AND NUMBER
Michigan
IDe ZIP CODE
Oakland
38 East Rutgers
13 SURVIVING SPOUSE
(If wife. give fl,ml! belor. fllst maffled)
14 WAS DECEDENT EVER
IN U S ARMED FORCES?
(Sf>("(I'Y Yt'$ 01 No)
NO
48340
Hary Deicheldor
17. DECEDENT'S EDUCATION (Specify only "_'6"" compleled)
15 ANCESTRY - MexJcan, Puerto Rican. Cuba , Central or South
Amencan. Chicano, olher HIspanic, Afro-American. Arab,
English. F/t'nch. FinnISh, etc. (Specify below)
Helsh/German
Hhite
ElementarylSecondary (0-12)
12
College (14 or 5+)
18 FATHER'S NAME (rust. Middle, Lasl)
19 MOTHER'S NAME (rllst. MIddle. Surnjme before hrsl mdffled)
Albert
J.
Harris
Geraldine
Harding
20a,' INFORMANT'S NAME (Type/Print)
20b. MAILING A.DDRESS (Street and Number or Rural Route Number, City or Vill"e, St,t" liP Code)
3e East Rut ers, Pontiac, Michigan 48340
22a PLACE OF DISPOSITION (I./.m. of Cemetery, Crematory,
or other place)
22b. lOCATION - City or Village, State
Perr
Mount Park Cemeter
Pontiac, tUchi an
24 LICENSE NUMBER
(of L,censee)
25 NAME AND ADDRESS OF FACILITY
Huntoon Funeral Home, Inc. 48340
79 Oakland Avenue, Pontiac, Hichigan
5336
26 PART I Enter the diseases. lnJurJes. or compllcallons that caused the death Do.!!Q! enler the mode of dyme, such as cardIac or respIratory
arrest. shock. or heart failure LIst onty one tause on each line
I tn':~~~~;m~~~ween
I Onset and Death
I c~)
I
I~J
I
I~~/
I
IMMEDIATE CAUSE (Final
disease or conditIon -----.
/esu1lmg In dealh)
1;(~1!:l{f:A CO~~~f) ~ J'f--t~A'~ C~
~tT~~R ~ M~[Q~~~~ eXA 'J(be <-, i:?~
~/uJh-~r ~'v1.-1.'~5
DUE TO (OR AS A CONSEQUENCE Ofl
SeQuentially lisl conditIons. {b
IF ANYlleadmg to Immediate
cause nter UNDERLYING
CAUSE (Disease or Inlury
Ihal initialed events
resulting In death) LAST
PART It Olher SignIficant conditions contnbulmg 10 death but nol resulting In the underlYing cause given In Part I
27. WAS AN AUTOPSY
PERfORMED?
(Yes or No)
27b WERE AUTOPSy fINDINGS
AVAILABLE PRIOR TO
COMPLETION OF CAUSE
Of DEATH' (Yes 01 No)
1-10
r~o
28
31;ClleCM 0 The case reviewed and determined nol 10 be a medical examiners case
~~7r) 0 ~t t~hee :f';~~ ~fa~eka:i~a~~~eanadn3fd~:e~~g~~I:nC~~S~~)O~~~O/lm~~~~hr ~~~~f
<.?Z
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(5, nature and Title) ~
~.~ 31b DATE SIGNED (Mo _ Day Yr) 31e CASE NUMBER
uZ
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~ ~ 31d PRDNOUN~EO DEAD (Mo, Day. Yr) 31e TIME or DEATH
ON
M
P M
32a NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH (ITEM 26) (Type or Print)
~oq~
(tJ4-1. 'L
ESCRIBE HOW INJURV OCCURRED
32b UCENSE NUMBER
(~/e: Ci '( 0 i { 2-
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33c TtME OF INJURY 33d
M
33e INJURY AT WORK
(Specdy Yes or ND)
331 PLACE OF INJURY ~ AI home, farm. streef. faclory
office bUilding. ele (Specdy)
33g LOCATION - Slreel 01 R F D No
City. Village Ot Twp
Slale
~4' REGISTRAR~Of~
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STATE OF MICHIGAN )
COUNTY OF OAKLAND ) ~
I, Tonni L. Bartholomew, Clerk of the City of Troy, Oakland County, Michigan, do hereby certify that the foregoing is a true copy of the record now remaining in my office.
~'?71,~
. Tonni L. Bartholomew, City Clerk
City ofTroy, Michigan This copy Is not valid unless displaying embossed seal and registrar signature.
WARNINGllt Is Illegal to duplicate this copy by Photostat or photograph. VALID ONLY WITH IMPRESSED SEAL.
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