HomeMy WebLinkAbout947060AFFIDAVIT OF SURVIVORSHIP $.."0 `667
I, William Harvey Gosnell, (the "Affiant"), being first duly sworn upon my oath, do hereby
depose and state:
1. I am of legal age and the surviving spouse of Emily Antoinette Gosnell. I have personal
knowledge of the fact that the Emily Antoinette Gosnell referred to throughout this Affidavit is one and
the same person as Emil Antoinette Gosnell who died July 2, 2008 referred to in that certain Death
Certificate certified by the State Registrar of Vital Statistics for the State of Colorado on July 16, 2008 and
attached to and recorded erewith.
2. At the time of her death Emily Antoinette Gosnell was an owner in joint tenancy with William
Harvey Gosnell, Affiant herein, of the following described real property situate in the County of Lincoln,
State of Wyoming, (the "Property"), to wit:
The Lots one (1) and two (2) of Section 13, in Township 21 North, Range 116 West of
the Sixth P.M.; Southeast quarter of the Southeast quarter (SE'/4SE%) of Section 7;
And Lots one (1) and two (2), North one-half of the Northeast quarter (NY2NEI/4), and
the Northeast quarter of the Northwest quarter (NE'/4NWI/4) of Section 18; all in
Township 21 North, Range 115 West of the Sixth P.M.; All in Lincoln County, State
of Wyoming, and containing 302.48 acres more or less
also known generally by the street address of: (vacant land)
3. That Affiant and Emily Antoinette Gosnell acquired their interest in joint tenancy in the
Property by virtue of that certain quit clam deed dated December 13, 2002 in which Emily Antoinette
Gosnell, also known as Emily Holec Gosnell, was grantor and Affiant William Harvey Gosnell and
decedent Emily Antoinette Gosnell were grantees in joint tenancy. Said deed was recorded March 3, 2003
under file number 888139 at Book 514 PR Page 028, in the records of the Lincoln County, Wyoming
Clerk.
4. This affidavit is executed pursuant to W.S. § 2-9-102.
Dated May 8, 2009.
Willi ey Gos 1
State of Colorado )
County of Teller ) ss:
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Subscribed before me on May 8, 2009 by William Harvey Gosnell.
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sion expires November 23, 2011.
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STATE OF COLORADO;
COLORADO DEPARTMENT: OF'PUBLIC.HEALTH;ANb NUIRONMENT
I HOLD TO LIGHT: TO: VIEWVATERMARK
STATE OF COLORADO.. STATE FILE NUMBER Cwp 6
CERTIFICATE OF DEATH
Amended 1875A
1. DECEDENT'S NAME (Fir-I. Middra. Last) 1 2. SE% 3. DATE OF DEATH IMonm. Day. Year)
/Emily:: Antoinette' GOSNELL Female July 2, 2008
A.. SOCIA
M, 3ECURI :Sa. AGE • Lash Sb. UNDER 1 YEAR . Sc. UNDER ,'DAY B:.OATE OF BIRTH 7. BIRTHPLACE (City and Sure or r-gn
NUMBER - 8lnhdey,Years) 05 aYs (Llonln, Day. Ynq C-1,Y)
87 HIS MI"' January 16, Kemmerer, Wyoming
0. A DECEDENT EVER IN ga. PLACE OF DEATH (ChecA;only unp
U.S. ARMED FORCES7'.: -
)V Yaa: ❑ NO HOSPITAL r OTHER f g
0 inpatlem O. ER/Outpagenl 0 GOA: ' ❑ Nmrsln Home R Residence O Other (Specify)
E. FACILITY NAME (it not inallfution; give Siraet and num6eq Qc, CITY, TOWN, OR LOCATION OF DEATH to. COUNTY OF DEATH
7180 Juniper Drive - Black Forest El Paso
10a. OECEDENT'$ USUAL OCCUPATION l Ob. 1 - U I E S(1 DUSTRY 11. MARITAL STATUS Marrletl, 1 SPOUSE 11 wile, glue meman name)
R aindol vvvirdonedudnp most orwo(King llte. Never Married, Widowed,
(t~l up nomad ' Dlvmeed (SpecrlN
William H. Gosnell
`Floor Manager - Air Force Academy Visitors'Center Married
134, EI C-sAE eft NTY 13C. CI V. TOWN, OR LOCATION i3d.STREETANONUMEER
Colorado E! Paso E!ack Forest 7180 Juniper Drive
13e. INSIDE 131: ZIP: CODE - 14. WAS DECEDENT OF HISPANIC R1OIN? 15. RACE: Ameticart n It
6;EOENT'SE U A i N peellYonly nipneal
CITY ISpadlY 1. ,or Yai • II Yes,.Pac11, Cubsn, fllack, Whllt, atg, ($pa0lly( pprada cOmpklYdl ElemaOWry or secondary
LIMITS? er PUsno RlCan, alcl Ig thr0uQh 121 COIIape1f31hromph 180r 17+1
ONa 80908 sp: o ~r,Yavea White 13
7, FATHER,NAMR tFlre6 iddfa, lu l 18. MOTHER-NAME IFirsl Mmdq, USt tM01dan Namell R NT•NAME and ratatunahlp to tla¢saeetl.
Ferdinand Holec Emily Svec William Gosnell - Husband
De. MET015 OF I N - - 20b. PLACE OF DISPOSITION (Name of ger0elely,
grem4q'10c. LOGAT10N -Coy or Town,3tete
urhar Plaq)
~ e X7 Burial O CTematlon p Remowl Ir¢m9ta1e
dlwnauon ootner(sp.Cilr)Eastonville Cemetery, Black Forest, Colorado
21a. -SIGNATURE OF,, FUNERALOIRECTOR OR ft83ON ACTING A&3UCti 21 b, NAME AND ADDRESS OF~FAGILITYt 1 I
I Swan-Law Funeral Directors
Ed Rbttenborn501 N• Cascade Ave. Colorado Springs, CO tip: 80903
2 GI$TRM $ 1 ATURE. 22b, DA E FI4ED IMopifrr flay. Yagt 11 r
3, F EAT A. DATE R 0 EAD -I 23„WA RGN RNOTIFIED
Month DAY Year out IYea I, No)
x:40 P M Jul 2 2008 3:40 P Yes
TOAl COMPLETED ON LY11Y CE RTI FYI NG PHYSICIAN To BE WelFLUTED fay CORONER
29 of a 0ut04mY Anow140Q9,040th ocCuffetl9 the timedale and place and due to 27, On thebes1601laaminall0 d/Of1 jill aticn. In m1,6011n0n death odovueg it the
the deueatel and men r ene e~to(ed. time, dale and platy, an u to the C~e (elan Antilles IaI4G.
OEM I
Slgnnure-~, 1 ~ 'a 0 tkrj- C t Signature
T 2E. DATE SIGNED IIAOnm, Day. Yeer) 29. OATS SIONEOIMdnrh, Day.Yeaf)
2 7/7 !o
_
30. NAME, TITLE ANOMAILING ADDRESS RTIFI R ORON RI YAVPnnq
,n1- /~ct~dcy.t~: D Iv~Q , Scc }c /ode, CuJorxdb SI'^r . [ o
3--° ,clh > l~_` wTJt 11. /a e7 . -S 2l16
Sf 09'
31. NAME OF ATTENDING YSI IAN IFO H N IFI R( ypWPrinq
a-+-- 32 ..MANNER OF DEATH 33L DATE OF INJURY 33n IM 330 Iqq~~~~ttRyy AT 39q DE$ORI HHQN INJ Y CURRfiD
1NJ4RY - WOflK?
(MOnIR Day. year)
Natural ' O pending
5 lowesttgaUOn: DYea 0, No
O AOCldehl
0 Undetermined
O suicide Manner 33e. PLA E F I N N..ltLIRY•At home, term, Mosel, fWWV. ri toe 33t. LOCATION (Street and Number or Rural Route Number, Wry, County, $total
0 H6mICICq bu110 etc ISt»cdY1
3a. IMMEDIATE CAUSE IENTERONLYONE CAUSE PER LINE FOR (&A (IIA AND (CA] Do nor ter mode of dying (e.0. Cardiac or Respiratory Atreet)alcn4, Interval between onset
PART
• ' (a) ~A alfr>< ca 8 T`cG3)L C e b i'C!r 31
CONDITIONS DUE TO ORA ACONSEQUENCE OF Interval belvrean once,
• IF ANY WHICH - - no death
GAVE RISE TO ` ibl
IMMEDIATE CAUSE E R AS A CONSEOU NCE OF
STATING THE Interval belwean ons6
VNOERLYING CAUSE - and death
LAST (el lot
PART OTHER SIGNIFICANT CONDITIONS -Conditions 4c'onlnbuling to death' but not mistodtpcaueeln' '34. AUTOPSY 3B: IF YES wen llndinpa considered.
It PARTI(e.g. alcOn0l abuse, obeamy, smoker):' ry ~j1P►EjtS r611 r ~F1.J EArs jytt ll'.Aµa 'iye, or Nor In delvmlNng tamed of death?
\ No
Jll1 1 6' 2DD8
DATE ISSUED
~t RONALD S. HYMAN
THIS IS A TRUE CERTIFICATION OF NAME AND FACTS AS STATE REGISTRAR
RECORDED IN THIS OFFICE. Do not accept unless prepared on
security paper with, engraved border displaying the Colorado state seal VIII VII I II I I II III II III II III II III II III II III II III VIII
and signature of the Registrar. PENALTY BY LAW, Section 25-2-:118,
Colorado Revised Statutes, 1982, if a person alters, uses, attempts t.o
~e use or furnishes to another for deceptive use any vital statistics record. S L 3 9 8 9 1 5 4 4
li ! 1 !
NOT VALID IF PHOTOCOPIED. REV 01/07