HomeMy WebLinkAbout946811
THE STATE OF WYOMING )
) ss.
COUNTY OF LINCOLN )
ûOú61.0
AFFIDA VIT OF SURVIVORSHIP
I, VAL DEE HEAP, being first duly sworn, states as follows:
1. Affiant is a Grantee of certain real estate with respect to the
decedents hereinafter referred to; therefore, Affiant has an interest in the real
estate that is the subject matter of this Affidavit.
2. Affiant states that ALVA HEAP, a/kla ALVA HAYDEN HEAP,
died at Thayne, Wyoming, on the 23rd day of April, 1998, 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. Affiant further states that BLANCHE HEAP, aIkIa BLANCHE
IRENE HEAP, died at Thayne, Wyoming, on the 3rd of December, 1994, the facts
of said death more fully appear nom the Certificate of Death, duly certified by the
State Registrar of Vital Statistics, attached hereto as Exhibit liB" and by this
reference incorporated herein.
4. This Affiant and his spouse, Carol LaMona Heap, who is also
deceased, acquired 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 of the books and records in said office. Said Warranty Deed reserved unto the
Grantors a life estate in the property that is more particularly described as follows:
Beginning at a point 45 feet East from the Northwest Corner of the
SEl/4NW1I4 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.
Affidavit of Survivorship
Page 1 of2
RECEIVED 4/29/2009 at 11 :39 AM
RECEIVING # 946811
BOOK: 721 PAGE: 610
JEANNE WAGNER
LINCOLN COUNTY CLEP'/ I/I::~~MERER, WY
5. This Affidavit is filed for the purpose of establishing the facts of the
deaths of the said AL VA HEAP and BLANCHE HEAP, who were the owners of a
life estate in the above-described property, pursuant to the provisions ofW.S. §2-
9-102 (1997).
OOó611
FURTHER AFFIANT SA YETH NOT.
DATED this ð/~Ì'~ day of April, 2009.
-Id it q¡~
VAL DEE HEAP '
The foregoing Affidavit was subscribed and sworn to before me by VAL
. Q'r,-j
DEE HEAP, thIS D~J.!.day of April, 2009.
WITNESS my hand and official seal.
.JAMIE M. JENKlf\JS . NOTARY PUBLIC
County of
Lincoln
State of
Wyoming
\
My Commission Expires May 19, 2012
.~........
My Commission Expires: YY'Ot~ \Ol 190 \?-
Affidavit of Survivorship
Page 2 of2
STATE OF WYOMING
DEPARTMENT OF HEALTH
--rÞ- /7
./
¡.
~
~
i
I
tyPE
OR"",,"
..
.............,..
I!lN:K
INK
FOR
INSTRUCTIONS
SEE
HANDBOOK
LOCAL FILE NUMBER
1. DECEDENT·N~E FIRST
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
HAYDEN HEAP
MALE
8J;'TE fiLE NUM~R
3. DATE OF OEAT~ (Mo..}'." )1.1
APRIL 23,
B. DATE OF BIRTH (Mo.. O-r. YrJ
MIDDlE LAST
2. SEX-
... SOCIAL SECURITY NUMBER
c.
1
Mlrut..
SEPTEMBE~8 1908
~!
i
!1
~
t\'
~
ø
"
!*
~
ív'YOMING
131; INSIDE CITY :LlMrTS1~>
(SpecIfy JIll: OI,~J .
NO; .
11; FATHER'8:N~E
~:: '
~\
~
~
k
~
~
~
.
~
~
~.
l~
PI
~.
~
i
~
..
1;
/jl
TYPE
OR PAINT
..
PERMANENT
INK
FOR
INSTRUCTIONS
SEE
HANDBOOK
'. )r;'
'\::)0)
VR 2-69
1/69 15M
LOCAL FIL£ NUMBER
1. DECEDENT-NAMe FIRST
STATE OF WYOMING
DIVISION OF HEALTH AND MEDICAL SERVICES
CERTIFICATE OF DEATH
ÜOû613
MIDDLE
LAST
Sf... TE FILE NUMBER
3. DATE OF DE" 1H (Mo~ Day. Yr,)
Blanche
Irene
December 3, 1994
4. SOCtAl secURITY NUMBER
6.0ATEOFBIRTH(Mo~ Day, Yr.}
May 1, 1 911
HOSPfTAl: 0 Inpøtleot 0 EAlOvtpø,I.,1 0 DO" OTHER;
1b. FACIUTV NAME (If nol ios,ilullon. 91'" .',ul lmd numÞ.,)
7a. PLACE OF DEATH (Checl( only øne)
o NtnhgHomø ~.sldenc. DOlhnrfSp.city}
7e. CITY. TOWN,OR lOCATION OF DEATH
7d. COUNTY Of DEATH
Lincoln
1~1096 Highway 89
Thayne
g. MARRIED, NEVER MARRIED, 10. SURVIVING SPOUSE (If wif.. giv. møidflll nB/n,,)
WIDOWED, DIVORCED (Spøc/fr)
Married Alva H.
8. STATE OF BIRTH {JI nof fn U.S.A. name colJII,ry}
Wyoming
11. WAS DECEDENT EVER IN U.s. ARMED FORCES?
(Specify y.. or no)
13.. RESIDENCE -STATE
13c. CITY, TOWN OR lOCATION
12b. KIND OF BUSINESS OR INDUSTRY
12a. USUAL OCCUPATION (Give Idnd of wark done during mos'
of working Nt., (tV"" /I rel".ftI)
Housewife
Homemaker
No
13b. COUNTY
Wyoming
t3e.1N51DE CITY UMlTS1
(S/18c1fy ye. or no)
Lincoln Thayne
14. WAS DECEDENT OF HISPANIC ORIGIN?
(Specify no or yes-II yes, spedly
CUban, Melllcal\ Puerlo Rican, EIC.)
Hi hwa 89
15, RACE-American k\( 1m,
Black, Whlle,Etc,
(Specify)
'6. DECEDENT'S EDUCATION
(Specify only hiphesl grade comple'ed)
Elemenlery/Secondary 10-121 College (1-4 or 5 of I
9
No
White
,.Jt){ Yes 0 (Specify'
Middle Last
Flrsl
Middle Malden Surname
17. FATHER'S NAME
First
18. MOTHER'S NAME
Philemon Titensor
Martha Moser
19b. RELATIONSHIP TO DECEDENT
Son
CITY OR TOWN
STATE
ZIPCOOE
83127
CITY OR TOWN STATE
........
Mortuar 45 Afton,
23.. On the basis 01 eKa"*talion and I or me'llgallon,ln my opinion dealh OCQrred
al 1"- time, date and place 1100 We 10 the cause(s) stated.
(SignatlHfJ snd Tille} ....
23b. DATE SIGNED (Mo. Osy, Yr.)
83110
PM
tg
J~
!g
.0
'"
23e. PRONOUNCED DEAD (Hour)
23c. HOUR OF DEATH
M
23d. PRONOUNCED DEAD (Mo~ Dsy, Yr.)
M
24. NAME AND AODAESS OF CERTIFIER (PHYSICIAN OR COAONfRI (Type Of Print)
Orson D.
110 H
25.. REGISTRAR
(Sign....) ~ ;11 ......
PART L Enl. lhe dls.e..1, In;Jrle.. or cOlT9licaUons lhat caused dealt\. Do not entar lhe mode 01 dying, such .. clII'dlac
25. or r&....tory III're.1. shock, Of heart 18IIure. UsI onty one causa on each lhe.
¡:¡ (.::;l-. Ae ( v1-~ ("'5 '-.})C ç£J ~
I =~~:~eF1
I OnIel and Dealh.
r
I
I .:::> .
IMMEDIATE CAUIE {Final
dllø..Otcondltlon
,esutllng n d..lhl ...
Sequentially 1111 condition.,
If "'f,leadlng to Immedlale
cause. Enler UMDEHL VING
CAUSE (DIs.... 01' ifP~
that nHlaled even..
relUlli1g In dealhl LAST
DUE TO (OR AS A CONSEQUENCe Of):
A--¡-þ-rv 9:=f9-f'ti9 ~ s
DUE TO (OR AS A CONSEOUENCE OF):
~ Q.-( L-
DUE TO (OR AS A CONSEOUENCE 0'9:
-§"
'<.J'
.
PART IL OTHER SIGNIFICANT CONOIT1QNS-Conditloos contrlbuling to dealh bul nol relaled 10 cause given in PART I
29. MANNER Of DEATlI
30a. DATE OF INJURY
(Monllt, OilY, Yur'
30b. TIME OF
INJURY
30e. INJURY AT WORK1
(Sp"clly ,.s or no}
lura'
Dp.......
lnvesUgalion
o Could nol be
DellJfmk"ted
301. LOCA nON (Stroot ond Nuonbur or nun" Roulu NunIlMlt, CII)' or Towu. SI.I"'I
Ac"""
M
JO.. PLACE OF INJUAY·AI homo,'erm, air_I, 'ecIOfY.
ollk:e bI.~lding, ale. (Specify I
""'do
-
THIS IS TO CERTIFY that this reproduction is a true
copy of a record on fi 1 e in Wyomi ng Vi ta 1 Records
Services, Cheyenne, Wyoming.
This copy is
sea 1 and the
Registrar is in
not valid unless
signa ture of
red.
it
the
bears a
Deputy
raised
State
Date Issued
December 12. 1994