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AFFIDAVIT OF SURVIVORSHIP
ûOv631.
STATE OF WYOMING )
) ss.
COUNTY OF LINCOLN )
I, Rollo L. Hansen, being of legal age and first duly sworn, depose and say as follows:
1. ThatAnn Hansen, the decedent mentioned in the attached certified copy ofthe certificate of
death, is the same person as Ann T. Hansen named as one of the parties in that certain
Quitclaim Deed, dated July 14, 2000, executed by Ann T. Hansen to Ann T. Hansen and
Rollo L. Hansen, as joint tenants with full rights of survivorship, recorded as Instrument
Number 866997, on July 14, 2000, in Book448PR at Page 568, 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:
Lot Numbered Seven (7) of Block Numbered Fifty-Four (54), ofthe Second
Addition to the Town of Kemmerer, Lincoln County, Wyoming as described
on the official plat thereof.
Also known as 1110 Beech Avenue, Kemmerer, Wyoming.
2. That I am the brother-in-law of Ann T. Hansen and thereby am a person interested in the
effective property or the title thereto and pursuant to § 2-9-102 W.S. (1980) herebyma1œ the
death a matter of record and certify that upon the death of Ann T. Hansen, her previous estate
in the property was terminated.
3. That the certified copy of the certificate of death indicates that Ann T. Hansen died on the
22nd day of June, 2008 in the City of Kemmerer, County of Lincoln, State of Wyoming.
Dated thiØ 1y...¡;'iay of March, 2009.
tØêIi~~
ROLLO L. HANSÉN
STATE OF WYOMING )
) ss.
COUNTY OF LINCOLN )
Subscribed and sworn before me by Rollo L. Hansen on this /03 {b day of March, 2009.
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NOTARY PUBLIC
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Probate\Hansen\Affidavit of Survivorship
RECEIVED 3/13/2009 at 3:55 PM
RECEIVING # 945869
BOOK: 717 PAGE: 631
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMME
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STArE OF WYOMING
bEpAfHf\IIE~T OF HËAL;fH
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HDEATH CERTIFICATe.
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Decedent: .
Name:
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Date oJ Birtb:
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..... State Filé NUrrtber: 2008-001870
Ann Hansen /
Femç¡lø')
OctoQer 14,\1.91
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H'\Soci~ISeçurity Number .....
Age attþ~ Ti[Tlø ofDeatry: 93 yè¡:¡rs
Date,and,Place ofD.eath: ....H·.'.HH'\ "'H"H H'. HH. ...... .......
Date· of Deàth:;Juóe 22 J200aAduaÎ HiP'Oynì¥ ofpë;3th: Lincoln
CityÖf Death:} KemmetÉ!r ..H' ....···...,..HH ". .' . ....... H'.' ......
Location: Nursing Home/Lopg tern1 Carer South Lincoln Nursing Center
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Åddith)naIDeêe~ent h1formaÌión:'.
Place ofBirth:H . Sublet; Wyoming ..,........
Re~!denc:e: ...'. HK~mmere,(WyQQ1il'1g
Mantal Statqs: .... VVf( owed' ... '.' .... '.' .
Armed Forces:Nd .
Name of Father: John Stefonick
.Maide~Nameof rVlqthør:Anna ryJajz:el
'Infor/T1ant: X ...\RblldHansép ·i...
Disposition:
Méth6dofDIspósitiòh;
PlaCe ofQiSþo$!tiqn:/
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Rêlatiþnshiþ:'sroth~r In.Law
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SouthLi.nco!ÒêerrJetery, Kémmerêr,WyómÎhg
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Cause of Death:. '" . . .... ...... .... '. ". . ."'. I
The ifnmedi13téc8usëjs Iist.Ødo'?the fit*tliriéfóllow~dbYâny uilder(YÎl1g cau$ës. (
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. ptherSignificáptPrPhditipns: NpfR~ëd~pe9~' ...,...., ........,
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Manner of Death: Natural Death
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Certifier:... ....
Name:
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bate Filed:
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Chris Kr~lI, M.D.
7} ~\ppyx,~ern~~(;r,
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iJune25, 2008 .....
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This is a tnm-ê'ertification of the document on file in the office of Vital
Records Servj~es, Gheyenne, V\lyoming.
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DATElSStJEb:
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July 08;2008..)
Interval:
...2 days
years
years
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