HomeMy WebLinkAbout876501WHEN RECORDED PLEASE RETURN TO
81650
Ms. Dona Killian
1134 East 900 South, #39
St. George, Utah 84790
property.
'BOOK 474 PR PAGE 4 1 8
AFFIDAVIT OF SURVIVORSHIP
DATED this /SST day of I c 2001.
L /2 1 9
Doris Killian
RECEIVED
LINCOLN 001.jNTY CLERK
G 1 01 :1' 9 1' r 1: 30
J AN
KE .MMERER, .J`Y0i'.(1!I'aG
The undersigned, DONA KILLIAN, being first duly sworn, hereby states
and represents as follows:
1. The undersigned is the surviving spouse of GLENN R. KILLIAN.
2. Glenn R. Killian died on August 9, 2001. Attached hereto as Exhibit
"A" is a Certificate of Death relating to Glenn R. Killian.
3. At the time of the death of Glenn R. Killian, the undersigned and
Glenn R. Killian owned, as joint tenants with full rights of survivorship and not as tenants
in common, the tract of real property situated in Lincoln County, State of Wyoming, as
more particularly described on Exhibit "B" which is attached hereto and incorporated herein
by this reference.
4. The undersigned is the surviving joint tenant with respect to said real
STATE OF UTAH
ss.
COUNTY OF Washington
On the day of die 2001 before me, the undersigned
Notary, personally appeared Dona Killian, who is personally known to me or who proved
to me her identity through documentary evidence to be the person who signed the preceding
document in my presence and who swore to me that her signature is voluntary and the docu-
ment truthful.
My Commission Expires:
2
419
Opda
NOTARY PUBLI ,X r ay,
Residing at: L
NOTARY PUBLIC
DEBRA TERRELL
1218 E. Riverside Dr.
St. Georgge, UT 84790
COMMISSION! EXPIRES
DEC. 3, 2003
S"PA"TE OF LflAH
Registrar'.
th I Informal on
IAN i Sllmeadend5r 18
the Yd5151 Ibex
un
mdR LOCAL FILE NUMBER
This
'.under`authority of section 26 -2 -22 ot
m DateIssued: B it Cif_° 'A. Ll �II9f��`.
H. DEPARTMENT OF HEALTH
�CATE OF DEATH
1953 As Amended.
NAME OF DECEDENT 'FIRST'; tl!t
..MID.E'i;�'s- 2. SEX 3a. DATE OF DEATH (Mo., Day, Yr.) 3b, TIME OF DEATH (24 hr. dock)
Glenn I
R ILLIAN Male August 9, 2001 1621
4. DATE OF BIRTH (M0.; Day Yrj i 5 gGE [.rif 8� rfb d ay tF UNDER 1 4EAR IF UNDER 24 HRS, 6. BIRTHPLACE (City B Slate or Foreign Country) 7. SOCIAL SECURITY NUMBER
r -r .M dhpl3 Ue v a Howls Mamas
May 8, 1932 Roosevelt, Utah 528 -34 -9776
ea. PLACE HOSPITAL,plor cod, r Na mavA ALL "OTHER LOCATIONS: Bb, NAME OF HOSPITAL NURSING HOME OR OTHER FACILITY
OF DEATH (if outside a faollIy, give sheet address of location)
(check only I I.1 IOpal em 5 Nursing Heine 8. Residence (any)
one) fl 2.ER/Qulpglient E odA r17Qlher(fpeuy) LDS-Hospital
J
8c. CITY, TOWN, OR LOCATION Of DE9T)Ij� d:000NT OF DEATH 9. .SURVIVING SPOUSE (1/wite, plus maiden name)
Salt Lake ',City Salt Lake Dona G. Christensen
pECEDEN 10, WAS DECEDENT MARITAL'STATUS' y13a DECEDENTS USUAL OCCUPATION (Give kind of work done 12b. KIND OF BUSINESS OR INDUSTRY
EVER IN THE U.S. r d uring most of working tile. Do NOT enter retired)
ARMED FORCES? 1 (4evejMA79d, V."5
1,Yes E 2 N0 'X 2 Marde4 JYer /r Salesman Utah Welders Supply
13a. RESIDENCE STREET ANQ'NUMBER 13b. CITY, TOWN OR COMMUNITY 13c. COUNTY 13d. STATE
1134 East 900 Sout r St. George Washington Utah
130. INSIDE CITY 131 ZIP COgE AS QEO DENT OF I)ISRANIC ORIGIN? [1 1, Yes 2. No 15. RACE Blade, While, Am. 16. EDUCATION (specify only highest
LIMITS? 3`perJM Indian (lobe may be entered), grade completed) Elementary or
u 847 1 M ex G ran Japanese, eta (Specify) S *'ary (0-12) College (13-16
1. Yes
2. No Qye6 Rren `.9.01her(Spacify) Caucasian 12
17. FATHERS NAME 'First, Middld Le3N r a 18. MAIDEN NAME OF MOTHER (First, Middle, Last)
PARENTS G ra n t B Ki1'll Lora Richins
19., 1112: E, RELATION$HIP, IMAI I f'i,/ DR ):}FJU0
EB S0RMA N 1
U; INFORMA WIFE: Dona :�G KiUL a"st ;900 South 4139 St.- George, Utah 84790
20. METHOD OF DISPOSITIO r 21ii DATEAFDISFOSIT,ION 216. PLACE OF DISPOSITION (name ofcemetery, 21c. LOCATION City erTown, Stale
crematory, or other place)
j r 1. Entombment 111 2 oonaR f-
13': 2001 Larkin Sunset Gardens Sandy, Utah
DISPOSITION 1:T1 4. Burial U 6. Cr9Malfoh 7 Remoy t.
22^6 NERAL BERM 23 LICENSEE NUMBER 24. FUNERAL HOM (Name and address)
r L v 22 111954 Larkin Sunset Gardens
F+ 25.. ATE DECEASED WAS.LAST 26 examiner wasdeathreportedloM.E,? u 1,Yes u 2. 10600 South 1700 East
ATTENDED BY CERTIFYING PHYS JA /I(y /enter the 41914. end boucreporled.
/r r Sandy, Utah 84092
4 2 E) M E C SE'NO HR. MO _DAY YEAR
I y
27a. CERT IER
27�
(ac,1 1. CERTIFYING PHYSICIAN Td ID bps/ of m Imowiedge deal i oCa1Red el gift time, dale, and place, and duo to the cause(s) and manner as elated.
CERTIFIER 2. MEDICAL EXAMINERILAW ENiiORCEMENT O ha, oA the b� of examination and/or Investigation, in my opinion, death occurred at the lure, dale, pleas and due to Um cause m
s) andannel 05 SIaleda_c .;1",./../,
27b. SIGNATURE TITLE OF CERT 27c. LICENSE NUMBER 27d DATE SIGN D (Man Day, Year)
28. NAME AND ADDRE$ F P hS W HUGER F IELhi E CAUSEOF DEATH (Item 31) (TypeIPdnf)
0..1.w,,o �,C yrto 3 33 S `700 E 5 L1°. ur 8
29, REGISTRAR'S SIGNATURE r
30a. DATE REGISTRAR NOTIFIED OF DEATH 300. DATE FILED (Mo., Day, Yr.)
REGISTRAR (Mo., Day, Yr.) �IJi� August 14, 2001
31. PART TER HE'DISEASEJ�NJUR1E$ 0R C0M LICATIONS,T1(AT CAUSED THE DEATH. 00 NOT ENTER THE MODE OF DYING, SUCH AS CARDIAC I Approximate Interval
#OR 'RESPIRATOR RREST I SNOCK OR HEART FAILURE LIST ONLY ONE CAUSE ON EACH LINE. Between Onset and
Death.
IMMEDIATE CAUSE (Float n
disease or condition reselling "t (P (C. k�t i cYa 5
in death) DUE TO (0)1 AS A CQN OF):
Sequentially (Ist conditions if
any leading t0 immediate T, O((9R AS A QONSEOUENCE OF): I S
cause. EnleruNDERLYJNG
CAUSE (disease er'(rlJury lhSt DUE 10( O R AS A CONSEQUENCE OF):
Initiated events resulting In
death) LAST
PART 5. Other SIgn0icahl Cu Ilona pJ dgbulm 1,4001Y 3,2 11 /O R U O 191014, TOBACCO USE B THE DECEDENT: 32a. W'S All AUTOPSY 33b. WSW:. AUTOPSY
CAUSE OF but not resulting In the uhdedy nor cause 91 P l in PERFORMED? FINDINGS AVAILABLE
DEATH nrdbaDly cantrlbulad to the cause of death. S. NON USER PRIOR TO COMPLETION
Wae{h underlying 80050 of death. OF CAUSE OF DEATH?
r 3 Did het centilbuta to the cause of death. B. UNKNOWN 1. yes 2. No 1. Yes 2. No
IF USER
4 I ow
s ynkrin in relation to the cause of death.
34. MANNER OF DEATH l D A TEp F I IURY (Md fly, Y/J 35b. THE OF INJURY 35s INJURY AT WORK? 354. P ACF 6 0, INJUR (speedy)
t hq e, facto, alma/, ffactory, r y i' (24 our Clack) I. Yes •2. No mace, mQng, etc
1- Natural III 2. Acd
1, orn?al mute number, city or town, county and state.) 35). U motor vehicle accident specify if decedent was driver,
r• 3. Suicide H
4,omldde r passenger or pedestrian.
05. Undetermined B.' 3 DESCRIDEHOWI JURYOCCLIRRED (enter sequenceof events wh/cheestlledlnin1 u N NATURE OF INJURY should be entered in Item 37
�UDH -BVR m If injured Invesligatron r sg r
Fbi 12; Purposely or
Rev.12198 Accidently
�,,iie. 1 :.9 1,
t Lake
fi t P T �cJ�s f l
sr,�r i
Barry E. Nangle g ,r
DIRECTOR OF VITAL RECORDS %:fi o���'?
iii B r \a+; II 4
loll '1 l it it WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES `1� 1(1 1 a.. �b
,r ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATION 1 1 1 li (j D
mod' .,.fi.m @k!(Ir,H ,,•r '4 0,.1515, Ai� n
(Ri.'f X01
Wyoming:
S: \7272 \Affidavit. wyo
EXHIBIT "B"
Property Description
The following described property is located in Lincoln County, State of
STAR VALLEY RANCH RV PARK PLAT ONE (1) LOT
ELEVEN (11) as platted and recorded in the Official Records
of Lincoln County, Wyoming.
RESERVING THEREFROM all rights, title, and interest in
and to any and all minerals and rights appertaining thereto.
Subject to all declarations of covenants, conditions and
restrictions of record.
3
42.E