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Home My WebLink About946810 THE STATE OF WYOMING ) ) ss. ) RECEIVED 4/29/2009 at 11 :35 AM RECEIVING # 946810 BOOK: 721 PAGE: 607 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY COUNTY OF LINCOLN AFFIDAVIT OF SURVIVORSHIP C-Oii607 I, VAL DEE HEAP, being first duly sworn, states as follows: 1. Affiant is the surviving spouse and the surviving tenant of a tenancy by the entireties with respect to the decedent hereinafter referred to; therefore, Affiant has an interest in the real estate that is the subject matter of this Affidavit. 2. Affiant states that CAROL LaMONA HEAP died at Worland, Wyoming, on the 14th day of October, 1993; the facts of said death more fully appear from the Certificate of death, duly certified by the State Registrar of Vital Statistics, attached hereto as Exhibit "A" and by this reference incorporated herein. 3. During the marriage of said decedent CAROL LaMONA HEAP, and spouse, VAL DEE HEAP, this Affiant, said decedent and this Affiant acquired as tenants by the entireties certain real property, by . Warranty Deed, from AL VA HEAP and BLANCHE HEAP, dated January 1, 1978, and recorded in the office of the County Clerk of Lincoln County, Wyoming, on June 10, 1998, in Book 412 at PR 711 ofthe books and records in said office, which property is more particularly described as follows: Beginning at a point which is 220 feet East from the Northwest comer of the NE1I4NW1I4 of Section 14, T34N, R119W, 6th P.M. Wyoming, and running thence East 306.66 "rods, thence South 180 rods, thence South of West 258 rods, thence North of West 62 rods, thence North 152.36 rods, thence East 13.34 rods, thence North 30,18 rods to the point of beginning. Also, the NW1I4NW1I4 of Section 14 and the NE1I4NE1I4 of Section 15, T34N, R119W, 6th P.M., Wyoming, containing 455 acres more or less, together with all buildings and improvements and appurtenances thereon situate, including all water rights. EXCEPTING THEREFROM the following described property, to- wit: Beginning 45 feet West of the Southeast Corner ofthe NWl/4NWl/4 of Section 14, T34N, R119W, 6th P.M., Wyoming, and running thence West 295 feet; thence East 295 feet; thence South 295 feet to the point of beginning, containing 2.0 acres, more or less. Affidavit of Survivorship Page 1 of2 ALSO EXCEPTING THEREFROM the following described property, to-wit: Beginning 45 feet East of the Northwest Comer of NEl/4NWl/4 of Section 14,T34N, R119W, 6th P.M., Wyoming, and running thence East 175 feet; thence South 498 feet; thence West 175 feet; thence North 498 feet to the point of beginning, and containing 2.0 acres, more or less. 00&608 AND RESERVING unto the grantors a life estate in the following described property, to-wit: Beginning at a point 45 feet East from the Northwest Comer of the SEl/4NWl/4 of Section 14, T34N, R119W, 6th P.M., Wyoming, and running thence South 300 feet; thence East 300 feet; thence North 300 feet; thence West 300 feet to the place of beginning, containing 2.06 acres, more or less. And also reserving to the grantors a life estate of one-half of the mineral rights in and to the above described property. 4. This Affidavit is filed for the purpose of establishing the fact ofthe death of the said CAROL LaMONA HEAP, who was the owner with the decedent's aforesaid surviving spouse of an estate by the entireties in the above described property, and to make an official record of the termination of the interests of said decedent n and to said property, pursuant to the provisions of W.S. §2-9-102 (1997). FURTHER AFFIANT SA YETH NOT. n "2.{~ DATED this d J day of April, 2009. (}~~1~~ VAL DEE HEAP The foregoing Affidavit was subscribed and sworn to before me by VAL ,j DEE HEAP, this {)2J::::' day of April, 2009. WITNESS my hand and official seal. JAMIE M. JENKINS - NOTARY PUBLIC County of Lincoln State of Wyoming My Commission Expires May 19,20·12 My Commission Expires: \'Y\Ct~ \°1, 9 Affidavit of Survivorship Page 2 of2 006609 TYPE OR PAINT .. PERMANENT BlACK INK FOR INSTRUCTIONS SEE HANDBOOK lOCA? JËN1~EA 1. DECEDENT· NAME FIRST STATE OF WYOMING DEPARTMENT OF HEALTH CERTIFICATE OF DEATH Carol 2. SEX Female STATE FilE NUMBER 3. DATE OF DEATH (Mo., Dtiy, ».) October 14, 1993 4. SOCIAL SECURITY NUMBER e. DATE OF BlmH (Mo.. Dq. Yr.) September 6, 1936 7a. PLACE OF DEATH (CtHIck only one} t!!1mJðL: Olnp.IIMI XI EA'OuI.,,"" 0 DOA ~: 0 Nu,,'"' Home 0 Anld.",,, 0 Doh.. "..clly) 7b. FACILITY NAME (II nof Inslltutlon. glYII slIe" ønd number) Te. CITV. TOWN. OR lOCATION OF DEATH Washakie Memorial Hospital Worland rd. COUNTY OF DEATH WashaJde ø. STATE OF BfRTH (If nor .h U.S.A., nllne country) California 9. MARRED, NEVER MARRIED, 10. SURVIVING SPOUSE (II 'Nfl., give fflIlden neme 'M'ãr°tDrë"dDISpecI/YI ValDee Heap Thayne 12b. KINO OF BUSINESS OR INDUSTRY Doctors Office 11. WAS DECEDENT EVER IN U.S. ARMED FORCES? {Specify )'8' Of no} No 128. USUAL OCCUPATION (Give hind 01 worlr done dtrIng mosr Medical 1eëiP¿;lã'Ï:y",Untdl 13.. RESIDENCE· STATE 13b. COUNTY 13c, CITY, TOWN OR LOCATION Wyoming Lincoln Box 177 138, INSIDE CITY LIMITS1 (Specify,.. 01' no 1 "'. WAS DECEDENT OF HISPANIC ORIGIN1 ¡Specify no or yes ~ If ye_, Ipeclly CUb8n, Mexleln, Puerlo RIcan, Elc. , G. DECEDEHT'S EotJCATJOIII (SPflCltr only htghe.r r¡mte compIeed 10-12 Colflge 11·"'01'6+) No 17. FATHER'S NAME Flral No Q{ Ve.O (Specify' Middle L.sl White 18. MOTHER'S NAME Flrlt Mlldln Surnlme . . ValDee Heap 1 ic. MAJUNG ADORESS P.O. Box Spouse LaMoni Farnham Call Dora McCann lVI, INFOHMAHT-NAMt:. (T)p6 or Pilnt 1Vb. RELATIONSHIP TO DECEDENT STAEeT OR R.F.D. NUMBER CITV OR TOWN STATE ZIP CODE 83127 Wyoming CITV OR TOWN . . Inc. lhe tNtl I 8'18 na Ion 8n or note. IgBt . my at Ih8 time. dl18 and place end due 10 .he causell) 1llled. (Slr¡nature Ind T1tfe ~ 23b. DATE SIGNED (Mo., Day, "'.J ..I rred October 15, 1993 9:22 P.M ~g i~ 1Ið .0 F 230. HOUA OF DEATH 22d. NAME OF ATTENDING PHY51CIAN IF OTHER THAN CERTIFIER (Type tv PrintJ 231:1. PRONOUNCED OEAD (Mo., DIY, \t.J M 23e. PRONOUNCED DEAD (HourJ -------------------- M 2-4. NAME ANO ADORESS OF CERTifiER (PHYSICIAN OR CORONEA)(Type or PrlnlJ Richard M. 510 South 15th st. Worland, Wyoming 82401 26b. DATE RECEIVED BY REGISTRAR (Mo., Osy, YrJ October 15, 1993 ApproJllmlle l,",erYIII Belween I an.et and Dlllh. I I I b. Sequenulny 1181 condlllon., II Iny, Mladlng 10 Immediate caua8. Enler UNDERLYING CAUSE IDllel1l or Injury Ihll Inlli&led evenl. resulting In d..lhllAST DUE TO (OR AS A CONSEQUENCE OF: DUE TO (OR AS A CONSeQUENCE OFI: .rjÞ ,OJ (;:)~ d. PART II. OTHER SIGNIFICANT CONDlTIONS·Candltlons conlrlbullnll to death but nol ,elatad 10 cause given In PART 1. Ilur.1 D Pending Invesllgation 308. DATE OF INJURY (MQnIh, Døy, YB.J 30b. TIME OF INJURY 3Oc. INJURY AT WORK? (Specify yes or noJ No 29. MANNER OF DEATH VA 2-89 2/91 15M ""cklo D Could nol ba...- Delermlned ':' M 301. PlACE OF INJURY-AI home, 'arm, tlreel, faclory, oJllce buildIng, ale. (SpeclfyJ 301. lOCATION (Slreel and Number or Aural Roule Number, City or Town, State) Accldenl Homicide THIS copy of a record on fi 1 e in Services, Cheyenne, Wyoming. IS TO CERTIFY that this reproduction is a true Wyomi ng Vi ta 1 Records Thi s copy is seal and the Registrar is in not valid unless si gna ture of red. it the bears a Deputy raised State October 21, 1993 c;;fk~.it- eglstrar Date Issued