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6010817405
STATE OF WYOMING )
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COUNTY OF LINCOLN )
SS.
RECEIVED 1/27/2009 at 2:25 PM
RECEIVING # 944902
BOOK: 713 PAGE: 667
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
OOô667
AFFIDAVIT TERMINATING EST ATE
I, Hal Titensor, being of lawful age and first duly sworn according to law, upon my
oath, depose and state:
1. That I am of adult age, a resident of Afton, Wyoming, and the Affiant
herein.
2. That by virtue of the conveyance which is recorded in the office of the
County Clerk for Lincoln County, Wyoming, located at Kemmerer,
Wyoming in Book 245PR on page 193 is recorded a Quit Claim Deed.
The Quit Claim Deed, dated the 25th day of November, 1986 conveys
unto Von S. Titensor and Hilda A. Titensor and their successors, as
Trustees, of the Von S. Titensor Revocable Trust dated the 12th day of
November 1986, the following described property, to-wit:
See attached Exhibit "A"
3. That said Von S. Titensor on the 8th day of July, 2004, died and a copy
of the original certificate of death, certified to as true an correct by public
authority in which the original of said certificate is a matter of record, is
attached hereto as Exhibit "B".
4. That by reason of death of said V on S. Titensor by reason of 2-9-102
W.S. (1980), the decedents interest and title in said conveyance has
terminated and title to the real property conveyed thereby has vested
absolutely in the Von S. Titensor Revocable Trust dated the 12th day of
November, 1986. continuously since the death of the said decedent.
FURTHER AFFIANT SA YETH NOT.
Dated / - ;¿ ;;l - ð ¿
~~
;//,,' ~ a ~~,
,/ Hal Titensor
State of Wyoming)
)ss.
County of Lincoln)
this
The foregoing instrument was subscribed and sworn to me by Hal Titensor
~ do day of ~)~~,t:! 1.~008 Q
V".-~. c:J ()O 7
Witness my hand and official seal.
ØJ!- ¡)d~
Notary Public
My Commission Expires:
t,.:lÔ-:!)OIl
JILL H. LARSON
County of'
Lincoln
NOTARY PUBLIC
State of
Wyoming
. ~.~y Commission Expires June 20, 2011
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// DATE FILED ,BY STATE REGISTRAR:
STATE OF IDAHO
_._, IDAHO DEPARTM!;NI Of HEAL TH AND W¡¡:LFARE
BUREAU OF HEALTH POLICY AND VITAL StATISTICS
Slale of Idaho
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IIMID "Al. ~""'~l tf.llSI!O AS """"'" fACIE !V1OII!'ICE Of' U" DEArnUl'JDl:II ,,,_,t,,,,,AND ,Jf_Ut.1I)OI1-f(I CODE
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STATE FILE NO.
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3. SOCIAL SECURITY HUMBER
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ð 490 E 4th Ave j!311J! fJ v.. 0 No
( .. ~ ï. MARITAL STATUS AT TIME OF DEATH ----it SURVIVING spouse·SÑÃMË(ifWiiê."V¡ve mø'den name,
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~ if 10. ~~~fs~·s. 1,.. .FATH,.E.R'S NAME (Firsl; Mlddië. \aši,-šûriîi~- -----.------- -- \ - - 'Ilb:eIR~HPLA .C.-.Ë...i...-.~I.Te~-.1..'. ñ1¡¡;;;õt.FO.-,....¡,..ñëõunï~I.-.
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8 '" U, METHOD OF DISPOSITION. 15. PLACE OF DISPOSITION (~'8me and address of cemelery, * 11. NAMEANo.~ ADDR~SS;O~.,.FU.~~o~~L FACILlTY..-;O- .'
jè Burial I r·J.C,re~lIon tn!malory,Olherplftce) Schwab Mo.ftiùary .':.~-:,;~.~.
:: ~:~I'..;"d.'ol1Eh'-nl Afton Cemetery 44 E _ 4th; Ave , Aftórt;<WY.
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* 17.. NAT EE OR PERSON ACTING AS SUCH * 17b.lICENSE NUMBER (OfllcenleeJ
M-676
PLACE OF DEAT!!J19-221
*. I., IF DEATH CCURREO IN A SPITAL: '* 1tb. IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPTTAl: " .,. ,.'.,- .
dO "npttlleril . ,O,;EfVOUlpollenI30 DOA : ~O Hospice 'aclUly ,0 Nursing home/long term care 'aclllly .0 D !~~~SS~home' ,0 ' 'iry;"-~: ':
* 20. FACILfTY NAME (If, om "gilly, glVlslreel and number) '" 21. CITY, TOWN. OR lOCATlONoräËÃTH;.~~D,ZIP CO -"',~2.CQUNn~,OF~D~R:~1
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25. DATE PRONOUNCED DEAD (~~~~ (S~.e.n ~,~~, , 2.6t¡T!~~ P.R~N.OU~~,ED~E.~f
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Jul 8 2004' (2<h,' JulL~O p~431 .
'I'" 21. CAUSE OF DEATH , ,'.....-. .,.-,; ,,_. <.,
PART I. Enler Ihe ~-:d seases. injuries, or compUcaUons u Ihal dlreclly causl!d the dealh. DO NOT enler terminal evenls sU:(;h_a~:C8I'dIÐC'-.. .^PPto~lmale:lnlerval:
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IF OtATH WAS
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This IS a true and correct,(eproduction of the document officially registered aM placed
on'lIIew:!n the IDAHO BUREAU OF HEALTH POLICY AND VITAL STATISTICS.
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DATEISSUED.·r7."h¡ /~2tJú'i 'ð'5z:e
Thl. 00" . "M ,." .l.",:;:;;:Z, 00 '"".,,, ""OO,
displaying state .seal' and signature of the Registrar, _ ____ _._______~!~TE REGIS::~!.______._____.____
___._.._______.....o-_.._~__.:...___':~~......._ ..--""'.._.--'-_______.~.._.________
Exhibit A
File 6010817405 Description
000669
The land referred to in this document is situated in the State of Wyoming, County of Lincoln, and is
described as follows:
Lot 1 Blocli 5 of Afton Townsite, Lincoln County, Wyoming as described on the official plat
thercof.
EXCEPTING THEREFROM the following desrcibed tract of land:
The South One Half of Lot 1, Block 5 of the Afton Townsite, Lincoln County, Wyoming
asdescribed 011 the official plat thereof.