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AFFIDAVIT OF DEATH OF TENANT
BY THE ENTIRETIES
STATE OF WYOMING
)
) ss.
)
000542
COUNTY OF LINCOLN
Cynthia A. Buckner, a/k/a Cynthia Ann Buckner, of legal age, being duly
sworn, deposes and says, in accord with W.S. § 2-9-102 (2003), as follows, to-wit:
1. That I was the lawful wife of Calvin Bruce Buckner at the time of his
death on February 15, 2008.
2. That Calvin Bruce Buckner, the decedent mentioned in the attached
certified copy of Certificate of Death, hereby made a part hereof, is the same person as
C81vin Bruce Buckner named as one of the parties in that certain Warranty Deed dated
August 25, 1986, executed by Thor Olney Taylor, a!k/a Thor O. Taylor, Grantor to
Grantees, Calvin B. Buckner and Cynthia A. Buckner, husband and wife, as tenants
by the entireties, recorded as Instrument No. 659816, on August 8, 1986, in Book 241
P .R., Page 364, in the Lincoln County Wyoming Clerk's Office, of the official records of
Lincoln County, State of Wyoming, concerning the real property situated in the County·
of Lincoln, State of Wyoming and described as follows, to-wit:
Lot Number Nine (9) of the Taylor 5th Subdivision as filed and platted in the
Lincoln County Clerk's office in Kemmerer, Wyoming. Sold subject to all
reservations, restrictions, covenants and roadways of record and vision.
Containing two (2) acres, more or less.
3. I hereby certify to the Lincoln County Wyoming Clerk that the above is
true and correc~ and request the Lincoln County Wyoming Clerk to transfer the above
described property into my name alone, to-wit: Cynthia A. Buckner, a/k/a Cynthia Ann
Buckner.
DATED this 4th day April, 2008.
RECEIVED 4/8/2008 at 10:35 AM
RECEIVING # 938124
BOOK: 691 PAGE: 542
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Affidavit of Death of Tenants by
the Entireties by Cynthia A. Buckner
1
000543
VERIFICATION
STATE OF IDAHO )
) ss.
COUNTY OF BEAR LAKE )
I, Cynthia A. Buckner, alk/a Cynthia Ann Buckner, being first duly sworn upon
my oath, depose and state that I am the Affiant iri the foregoing entitled action; that I
have read the foregoing Affidavit of Death of Tenants by the Entireties, by me
subscribed; that I know the contents thereof and I verily believe the statements therein
contained are true.
DATED this 4th day of April, 2008.
~/&dL/.ji!U{¿'JÚ-fØValrq ~&ø..d/t#-/Æ~
Cynthia A. Buckner, alk/a Cynthia Ann
Buckner
Subscribed and sworn to before me by Cynthia A. Buckner, alk/a Cynthia Ann
Buckner, this 4th day of April, 2008.
WITNESS my hand and official seal. _ -Y ___
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Residing at: Montpelier, ID
My Commission Expires: 01/27/2011
Affidavit of Death of Tenants by
the Entireties by Cynthia A. Buckner
2
CERTIFICATE OF DEATH
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State File Number: 2008001953
Calvin Bruce Buckner
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DECEDENT INFORMATION
Date of Death: February 15, 2008
City of Death: West Valley City
Age: 56
Place of Birth: Witchita Falls, Texas
Armed Services: No
Spouse's Name: Cynthia Ann Chapman
Industry/Business: Utility .
Residence: COkeville, Wyoming
Mother's Name: Mary Sue Seal
Facility or Address: Pioneer Valley Hospital
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Time of D~ath:
County of Death:
Date of Birth:
Sex:
Marital Status:
Usual Occupation:
Education:
Father's Name:
Fac,ili,o/ Type:
<"·:·'·',,"~:\¡~i~'.' "~'f.J'~':;
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16:03
Salt Lake
August 5, 1951
Male
Married
Journeyman Lineman
Some College but No Degree
Calvin .t.aVerne Buckner
Hospjtaì Inpatient .
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INFORMANT INFORMATION ....
Name: _:' Cindy Ann Buckriéf'!' _, ,;,. .Relationship:." . 'Wifé;:',;'~
Mailirg Address: P. O. Box 1~~l-CokexjlL~,y,vYo..~in~83114:' '.; . '.
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DISPOSITION INFORMATìoN ._;i,_'-'~._..~,,"., ..,. I, ,..";}'
Method of Disposition: Crematié)n .,,' .:" ····.;,..,...:.;:;·Qate·öfQisposition: February 21 '20()8
Place of Disposition: Utah Fu'herafbire¿tó'is Cren;¡atiçn Ci3r1ter, ~outh Jordan, Utah ,":;"'.. ,y",::.;
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FUN-ERAL HOME INFORMATION '._.,. ~'. " if -'::'>~'!!' ,"','.:. ,.- :,:,.",,;¡,."'"
Funeral Home: Valley View Funeral i;()me'''~;:\,
Address:. 43:3~ West ~100 South,vy,est Va!.I~Y.Çi~Y,:H1(3hª.~1,20
Funeral Director: D.~v~~ Barthþlomew> ';'.>'" .' ,'..
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MEDICAL CERTIFICATION .,.t::". i.;?i~;'., ,. '., "f \" ",j_,'
Certifying Physician:~9rch¡:¡r~t .êober MD, ~~~4West9000 South, SUite209/VX~~t\Jordan, U.~~ah 8~Q8qi-',
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CAUSE QF DEATH \i~~
CoronarY artery disease :;;:
Tobacco Use: . Uhknown if LJser ::, ' ..'
Medical Examiner Contacted:J' g. Autqpsy Perfôrrî\~,d: Nò
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February 21,2008
This is an exact reproduction of the document registered in the State Offiþe of Vital Statistics.
Security features of this official document include: Intaglio Border, V & R images in top cyclolds,
ultra violet fibers and hologram image of the Utah State Seal, over the words "State of Utah". This
document displays the date, seal and signature of the State Registrar and the County/District Health Officer.
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Barry E. Nangle, Statë Registrar
Office of Vital Statistics
Ilml~n~lllllllmlll . d:.:.'~
* 0 6 J. 5 6 5 J. 7 7 * Director/Health Officer
County/District Health Department '