HomeMy WebLinkAbout945231
RECEIVED 2/12/2009 at 11 :36 AM
RECEIVING # 945231
BOOK: 715 PAGE: 292
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP AND TITLE
000292
ROGER CLARK DEBLOOIS, also known as ROGER C. CLARK, of lawful age and being first duly
sworn upon his oath deposes and states as follows:
1. That he is a person with personal knowledge of the facts hereinafter set forth;
2. ROGER CLARK DEBLOOIS, also known as ROGER C. CLARK, and MAXINE C. DEBLOOIS, also
known as MAXINE ANN DEBLOOIS, husband and wife, hereinafter described as tenants by the
entireties or as joint tenants with right of survivorship, purchased Real Property.
Property is described as: Lot 182 of Star Valley Ranch RV Park PLAT 1 as platted
and recorded in the official records of Lincoln County, Wyoming, together with all
improvements thereon situate.
Subject to any reservations, restrictions, covenants, conditions and easements of
record.
3. On January 8, 2008, MAXINE C. DEBLOOIS, also known as MAXINE ANN DEBLOOIS, passed
away, thus ending such tenancy; a certified copy of her death certificate is attached. Said
property then became the sole property of ROGER CLARK DEBLOOIS, also known as ROGER C.
CLARK.
4. This affidavit is made in support of the Title to the above described Real Property being
transferred into the name of ROGER CLARK DEBLOOIS, also known as ROGER C. CLARK.
5. Further affiant sayeth not.
~ ~ .P.t~
ROG CLARK DEBLOOIS
~
STATE OF Q\\~Or-cx.-
COUNTY OF "\\ l.Y'f\GL-
)
) SS
)
The foregoing instrument was acknowledged before me on \.... L- "\ -0 L by ROGER CLARK
DEBLOOIS.
(Seal)
hand and official seal.
"OFFICIAL SEAL"
Mary Walter
Notary Public-Arizona
Yuma County
'... Mv CQmmi sion Ex 'res 10 27
'··xþ~t:·;~~\~- .
^
Signature of Notarial Officer
My co
Notarv PubÚc
Title and Rank
STATE OF ARIZONA
000293
ORIGINAL
SïATE
COpy
STATE OF ARIZONA
DEPARTMENT OF HEALTH SERVICES· OFFICE OF VITAL RECORDS
CERTIFICATE OF DEATH
DEATH NO.
D-10£008. 0011i2
NAME OF
DECEASED
A. FIRST
B. MIDDLE
C. lAST
DEBLOOIS
SEX DATE OF MONTH DAY YEAR
FEMALE DEAT1i JANUARY 8, 2008
2. 3.
IF YES, INDICATE MEXICAN. SPANISH. PUERTO RICAN, WAS DECEASED EVER IN U;S. ARMED FORCES?
CU8AN, ETC. (SPECIPI YES OR NO) NO
4C. 5.
ac. HOSPITAL OR OF RESIDENCE, GIVE STREET ADDRESS)
~NREGIONAL MEDICAL CENTER
ANN
MAXINE
WAS DECEDENT OF HISPANIC ORIGIN:
(SPECIFY YES OR NO)
'8. NO
68. TOWN OR CITY
60.
oDOA
o OP EMER.
IN PATIENT
{IF WIFE, GIVE MAIDEN NAME}
1.
RACE (e.g.. white. black, American Indian, (specify tTlbe)elc.
SPECIFY:
WHITE
4A.
PLACE OF
DEAT1i
YUMA
6A. COUNTY
YUMA
SURVIVING
SPOU'ROGER
10.
~~eA~~s~~UV:~~~~ I~~,¡:=~~ ::,~r
14AJ:IOMEMAKER
r'I)I;CAT!:)N
HIGIIES r GRAUE COMt'L.EfED
IF UNDER 1 DAY MARRIED, NEVER MAARIED,
HRS. MIN. W'W,ft"ffDD (SPECIFY)
9.
SOCIALSECURITI NO.
FERN
6.
DATE OF
BIRTH
7. MARCH
AGE (YEARS
LAST BIRTHDAY)
~73 . 6B
CITIZEN OF WHAT
COUNTRY?
MONTH
DAY
YEAR
1934
KIND OF BUSINESS OR INDUSTRY
23,
148. OWN HOME
STATE AND
CITY OF 81RTH
(II not in USA. name counlry)
l'
H!.
'-!::>\\' '.1J"it; IN ,~i7crJ..\7
"UTAH WASATCH
L''3Uf!.
REm'ZONA
15.
STREET ADDRESS OF R.F.D,
159 ~,:>CC:)r:-
10 YEARS
16.
COLlEOE
(1íors+)
85367
151M !":',\TË
17.
ELEMENTARY SECONDARY
(o-12)
PREVIOUS STATE
OF R"tff'JtlI
16.
MOTHEA'S MAIDEN
NAME
ON RESERVATIONS
(SPECI'Ñð'S or NO)
15G.
C. LAST
1sA.
B. MIDDLE
188.
C. lAST
FROYD
IsE13276 E.
54TH ST.
A. FIRST
FATHER'S A. FIRST
;:M"wALLACE
CARRUTH
ZIP CODE
20.
ADDRESS
Cln' AND STATE
13276 E. 54TH ST. YUMA, AZ 85367
23.
GERT. NO.
STREET I~O.
RELA110NSHIP TO
:~sgIßAND
EMBALMER'S SIGNATURE
V~~ NOT EMBALMED
INFORMANT'S SIGNATURE
BY
21þ>ROGER DEBLOOIS
DATE
yUMA AZ
278.
CERT. NO.
1196
2c¡e
Y OPINION DEATH OCCURRED
NER :')1",.1EO.
BURIAL, CREMA nON,
REMOVI\h OT1iER Ì~"i.~)
2'. CRt;MAT ON
FUNERAL HOME
CITY AND STATE
pNSET VISTA FUNERAL HOME 11357 E. 40TH ST. YUMA AZ 85367
1> ~
j"'Z
q ?;O
"it;'!
5ffi~
zu~
11 ..
~~ I-
~~ ~¡¡¡1:
!l;Sa: 'Ætr~
Š-,o~~f£ð
lilt) ~u.~
~ @ -ffi
I-:f
TO TI-IE BEST OF MY KNOWLEDGE.
DUE TO THE CAU5E{S STATED.
30. ~~~ii'JE ~
ARED AT THE TIME, DATE AND PLACE AND
HOUR OF OEJ\TH
32.04:43
AN OF OTHER THAN CERTIFIER (Type or print)
33.
NAME AND ADDRESS OF CERTIFIER, PHYSICIAN, MEDICAL EXAMINER OR TRIBAL LAW ENFORCEMENT AUTHORITY
~P'~~~SAM FAYAD M.D. 25.03
.-L __...1-.---
WAS CASE REFERRED TO MEDICAL EXAMiNER
(Specify Yes Of No)
50. 'i ES
'6.
MANNER OF DEAìH
~~~~L
o ACÇ DENT
MO
DAY
DATE OF
INJURY
o HOMICIDE
o ~NE:s':,.TION
o UNDETERMINED
STATE
51. 0 BUICIOE
SUPPLEMENTARY ENTRIES
~ ~. M
~~~T~F INJURY tAl ~om8, farm, sllast, factory. office building, elc.)
56.
STREET ADDRESS
CITY OR TOWN
I
156.
¡
-----.--
. JAN 1 5 2908
~þ~
PATRICIA ADAMS
ASSISTANT STATE REGISTRAR
This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS,
ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA issued under
the authority of AR.5. 36-341, and by direction of:
This copy not valid unless prepared on a form displaying the State Seal and impressed with the raised seal of the issuing agency.