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Affidavit of Survivorship
000723
I, Jane L. Hill, being of lawful age and duly sworn according to law, upon my
oath, depose and state:
That under the date of June 7, 1999, for valuable consideration, Leisure Valley,
Inc., by deed of that date, which deed was duly filed of record in the Office of the
Lincoln County Clerk, on June 21, 1999, in Book 431 PR, Page 771, conveyed to William
B. Hill and Jane L. Hill, as joint tenants, the following described land, to-wit:
Lot 121 of Star Valley Ranch RV Park Plat 1 platted and recorded in the official records
of Lincoln County, Wyoming
That under the date of July 28, 1999, for valuable consideration, Leisure Valley,
Inc., by deed of that date, which deed was duly filed of record in the Office of the
Lincoln County Clerk, on August 18, 1999, in Book 434PR, Page 609, conveyed to
William B. Hill and Jane L. Hill, as joint tenants, the following described land, to-wit:
Lot 120 of Star Valley Ranch RV Park Plat I platted and recorded in the official records
of Lincoln County, Wyoming
(l
That by reason of said conveyances aforesaid, the said William B. Hill and Jane
L. Hill (husband and wife) as joint tenants, became the owners of said real property, and
title thereto vested in them continuously from the date of said conveyances to the date of
death of William B. Hill, on the 15th day of November, 2007. That by reason of and
upon the death of William B. Hill, title to the above described real property vested
absolutely in Jane L. Hill, as surviving joint tenant.
Affiant avers and certifies that William B. Hill is the identical party named with
Jane L. Hill 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 ~ 9 day of ~.. ' , 2008.
V
da~~7'k
t/ ' Jane L. Hill
State of FIt)n' r/À )
County of Ese ~.~ l:'" )
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RECEIVED 2/4/2008 at 4:15 PM
RECEIVING # 936727
BOOK: 685 PAGE: 723
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Subscribed and sworn to before ~ a notary public in and for said County and
State, by Jane L. Hill, this.2.!:L day of 1'YtL1.('µ"', 2008.
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WITNESS my hand and official seal.
DEBRA STORY ,
"'~:::"~~';-'" Notary Public - State of Flonda
l~O~P';¡~3¡ ~(>\MY Commission Expires May 26, 2009
r'* ~ :.'rE Commission # DD 419452
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TYPE OR PRINT
WITH BLACK INK
DECEASED
If deølh occurred in
an insUtulion, see
HANDBOOK, regerlling
completion of
RESIDENCE items
For RESIDE~'iN"'ÌI;
enter .-elual ".Uon:::' .
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PARENTS
INFORMANT
DISPOSITION
MISSISSIPPI STATE DEPARTMENT OF HEALTH
VITAL RECORDS
t.()Q~?4
FILING'"
DATE N OV 2 9 2lÌÒ1
1, NAME Firsl
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CERTIFICATE OF DEATH(
STATE OF MISSISSIPPI
2. SEX
Middle
3b. DATE Of; DEATH (Monlh. Day, "'at)
. -
WilillltJ) ,
Bennett
4, RACE (Specify While. Black,
American Indian. ele.)
7b, CITY OR TOWN OF DEATH
BILOXI
Mattie"
20<: LOCATION (City and Slale)
21a.
..
21b, FUNERAL HOME-NAME A ~ MISSISSIPPI I,D, NUMBER MAILING ADDRESS (Slreel and number 0 roule and box number. City or lawn, Slale, ZIP code)
Marshall Funeral Ho~ . 24 F 825 Division St
PRONOUNCEMENT 22a, PERSON WHO PRONOUNCE~DEATH-NAME AND TITLE (Type ~r print)
STEPHEN L. FARRcW", MD
23a. CERTIFIER-NAME., (Type or Prin~,\
STEPHEN L. FARR ¡-MD
I 24a, To Iha best of my dg
T~is and manne_~
Mississippi släio:,: : i '~~~tion I SIGNATURE .....i'·
::ro ~. ::~:: ,·C(i~$~:~t.~b.PATE S19t1
- ,...;, '~jJ ~~¡;':':/.\..¡
CERTIFIER
CAUSE OF DEATH
Conditions. if any,
which peY8 rise to
ImmedIate caUSe
stallnli the
underlying
cause last
Had Decedent
been Pregnant
Within 90 Days
Prior to Death?
DYes 0 No
I 22b. PRONOUNCE
, ON NOV
MAILING ADDRESS (Slreel and number
25. Ö~~:\, '::J.I:¥,"",E ',',.': i':'".:,:i .
~:USEÖ " r <a) SOPHAGEALCANCER
{ : DU ro. OR AS A CON:~~U":~CE ~~ cause only):
I (b)
: DUE TO. OR N3 A CONSE~UENCE OF (Enla' one cause
I (c)
26. PART II: OTHER SIGNIFICANT CONDITIONS-Conditions conlribullng
givan In PART I
Usa if I 29a. ACCIDENT, SUICIDE, HOMICIDE, PENDIN 29b. DATE OF INJU
dealh INVESTIGATION, OR UNDETERMINED
NOT I (Specify) I m,
due to I I I
naturel, 2ge, INJURY AT WORK ; 291, PLACE OF INJURY (Specify Home, Farm. Slreet,: 29g, LOCATION
cauaesl (Yes or No) Factory, Offica building, _etc,)
I I