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RECEIVED 5/22/2009 at 12:33 PM
6010917914 RECEIVING # 947330
BOOK: 723 PAGE: 595
STATE OF WYOMING ) JEANNE WAGNER
SS. LINCOLN COUNTY CLERK, KEMMERER, WY
COUNTY OF LINCOLN )
I:: OV595
AFFIDAVIT TERMINATING ESTATE
I, Katherine F. Ross, Trustee being of lawful age and first duly sworn according to
law, upon my oath, depose and state:
1. That I am of adult age, a resident of Lincoln County, Wyoming, and the
Affiant herein.
2. That by virtue of the conveyance which is recorded in the office of the
County Clerk for Lincoln County, Wyoming, located at Kemmerer,
Wyoming in Book 289PR on page 607 is recorded a Warranty Deed. The
Warranty Deed, dated the 5th day of September, 1990 conveys unto
James A. Ross and Katherine F. Ross, Trustees of the Ross Family Trust,
U/D/T dated June 4, 1984, the following described property, to-wit:
Lot 14 of Star Valley Ranch Plat 14, Lincoln County, Wyoming as
described on the official plat filed on August 10, 1977 as instrument No.
496705 of the records of the Lincoln County Clerk..
3. That said James A. Ross, Trustee on the 10 day of
nPcember ~ 90n7 , died and a copy of the original certificate of
death, certified to as true an correct by public authority. in which the
original of said certificate is a matter of record, is attached hereto as
Exhibit "B".
4. That by reason of death of said James A. Ross, Trustee by reason of 2-9-
102 W.S: (1980), the decedents interest and title in said conveyance has
terminated and title to the real property conveyed thereby has vested
absolutely in Katherine F. Ross, as sole Trustee, continuously since the
death of the said decedent.
FURTHER AFFIANT SAYETH NOT.
Dated
State of Wyoming )
County of Lincoln)
)ss.
Katherine F. Ross, Trustee
The foregoing instrument was subscribed and sworn to me by Katherine F.
Ross, Trustee of the Ross Family Trust, U/D/T dated June 4, 1984 this o? C7
day of May, 2009
Witness my hand and official seal.
Notary Public
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My Commission Expires:
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NOTARY PUBLIC
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County of
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My Commissi
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COUNTY OF LOS ANGELES DEPARTMENT OF PUBLIC HEALTH 1 f y
06596
CERTIFICATE OF DEATH 3200719051444 1
MATE OF CAIIFORNN
STATE FILE NUMBER USE BUCK INK fRIIY/NOEMBUREB, Y/IUIEfN1iS OR ALTEMTMN49 -
Vdi REY1 LOCAL REGISTRATION NUMBER
1. NAME OF DECEDENT - FIRST (Owen) 2. MIppLE 1, LAST IF* 11)
a ALFRED JAMES ROSS JR.
I-
o ANA. ALSO KNOWN AS - In". full AKA (FIRST, MIDDLE, LAST) C DATE OF BIRTH .Ak1I,,y S. AGE YN. IF UND R Y F UNDER 2/ S. BEK
JAMES A. ROSS M°°Ib' I HIS W"N°` M
y 08/03/1927 80 I
e. BIRTH BTATEMOREIGN COUNTRY 10. SOCIAL SECURITY NUMBER 11. EVER IN U.B. ARMED FORCER] 12. MARITAL STATUS (et TNS M DmIn) T. DATE OF DEATH mmlddn°yy e. HOUR 114 ?bun)
ID YEB ODNK MARRIED 12/10/2007 2355
IS EgN:A ONNedNdnS LOF"N'n 1//18. WAS DECEDENT HIBPANICMTINO(ANSP-111111 IN We. Ne-06' 1- 11, DECEDENT'S RACE - UP I13,evae mly 1 B,HN1eee worFebeal on beoki
MASTER'S DYE. ❑X ND CAUCASIAN
W 17. USUAL OCCUPATION - TIP, 11 Ink for m,al of Ale. DO NOT USE RETIRED 11, KINDOF BUSINESS OR INDUSTRY(.,.. pInry elon,reed -pt., -M epenry;nOJ 1S. YEARS IN OCCUPATION
BUSINESS MAN ELECTRONICS _40
20. DECEDENTS RESIDENCE (8111,1 and
number or IoceUON
567 COUNTRY CLUB WAY
N 9 21. CITY 22. COUNTYIPROVINCE 23. 21P CODE 24. YEARS IN COUNTY 11, STAYPJFOREION COUNTRY I
THAYNE LINCOLN_ 93127 17 WY \
28. INFORMANTS NAME. RELATIONSHIP 21. INFORMANTS MAILIN ADORES.(SI-ISN1 ..b., .,..I IN, nwnbIN, dryor I-,,IMe, 21P) .1
a KATHERINE A. ROSS, WIFE 567 COUNTR: CLUB WAY, THAYNE, WY 93127
20. NAME OF SURVIVING SPOUSE FIRST 22. MIDDLE 30. LAST(M.1,1 BNim,l
n Rz KATHERINE A MILLER
O 31. NAME OF FATTIER - FIRST 32. MIDDLE 33. LAST 34. BIRTH STATE
s ALFRED JAMES ROSS WI
wo
C 38. NAME OF MOTHER FIRST
30. MIDDLE 37. LAST(Mnd,n) 3e. BIRTH STATE
y NELLIE A. BROWN CO
3s 39.DlSVOemo14 OATEmnvdpeoy 40.PlACEOFXINALDISPOSITION MELROSE ABBEY MEMORIAL PARK AND MORTUARY,
Q 12120/2007 2303 S. MANCHESTER AVE., ANAHEIM, CA 92802
CU 0 41. TYPE OF DIBPOSI110N(8) ,t 42. SIGNATURE OF EMBALMER 0 UCENBE NUMBER
CR/BU NOT EMBALMED ; .
1a~ -
= U 11. NAME OF FUNERAL ESTABUBFEAENT 45. LICENSE NUMBER 11, SIONATVRE OF LOCAL REGISTRAR I 47: DATE mMdao,yy
LL O DOUGLASS AND ZOOK MORTUARY INC FD221 ► JONATHAN FIELDING; MD . ® 12120/2007
101. PLACE OF DEATH 1D2. to No PITAL, SPECIFY ONE 103, IF OTHER THAN HOSPITAL. SPECIFY ONE
o USC UNIVERSITY HOSPITAL. X❑IP OERmvODOA OH,egee On A.TC ❑I°1 °T° Oom,
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G 104. COUNTY 106. FAC.LITY ADDRESS OR LOCATION WHERE FOUND 131-1 BM-INT r lanpon) IN. CITY , -
Ul LOS ANGELES 11500 SAN, PABLO ~T. - LOS ANGELES
fol. CAUSE OF DEATH Ell., IM Ohln of..m.-d Inlud,e, or wIppceUOne- Lein d0edly awml OWN. DO NOT wmin, ImminAl,,mle such T§nelMenn Oft- IN DEATH REPORTED T OORONEA7
a,,iraeo eneN, negntoryFinest, nveMtlculer RbdOelron MlAOM MBrAnpIM e801apy. DO NOT ABBREVIATE.
oUN Rld NO
OYE
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IMMEDIATECAUSE W CARDIOPULMONARY ARREST-
(AT,
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NO
OBMIUOn nw4
2 DAYS
ISM-NAMS.
In dealh) (8I RESPIRATORY FAILURE (F1)
pal I .
Sg-1101
10B. BIOPSY PERFORMED
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° dBem If.ny, 7 DAYS
UYEB ❑
. X NO
leedr,p to uuee (C) ICt7
Line A EIr CHRONIC MESENTERIC ISCHEMIA
110. AUTOPSY PERFORMED?
o
CAUSE(d.n.e, 1 YEAR..."
In)u
ma
DYE. ONO
w
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Im ;DTI
INileled the .-I,
111.UBED IN DETERMINING CAUSE?
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,sulpnp In tlanh) LAG T -
❑YEB ❑ NO
112.0 uIER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RF. F ULlIN 01N TI IE INOE R LY I NO CAV SE GIVEN IN ICI. -
REPERFUSION OF LIVER; AORTIC STENOSIS
113. WAS OPERATION PERFORMED FOR ANY CONOI TION IN ITEM 107 OR) 127 OF To$, In lylN It openllon end dale,) _
MESENTERIC BYPASS 11/29/2007
13A IF FEMALE PREGNANT U4 LAST YEAR?
❑ ❑
YES NO LINK
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114.1 CERTTT THAT TO THE BEST OF MY KNUYAEbOE DEATH OCCURRED
AT THE HOUR DATE. AND PUCE STATED FROM THECAUSE86fA7ED.
118.SIGNATURE ANO TITLE OF CERTIFIER C
118. LICENSE NUMBE0.
117. DATE nxnlEaOe/y
<
DewdentAIRnftdIII- DeoedeNLUlBSenAM.
/VINCENT LOPEZ ROWE M.D. ®
G76069
I
12/20/2007
mn.AM , .mm/eaxyy
118. TYPE ATTENDING PIttSIC1AN8 NAME, MAILING ADDRESS, LIP CODE
VINCENT LOPEZ ROWE M.D.
u
11/06/2007 12/10/2007
1200 N. STATE ST. #9442, LOS ANGELES, CA 90033
-
l is. I CERTIFY THAT M MY OPINION DEATH OCCURRED AT THE HOUR. DANE. AND PUCE STATED FROM THE CAUSES STATED.
120. INJURED AT WORK? '
121. INJURY DATE mMdd'ayy
122. HOUR G4 Hours)
MANNER OF DEATH ❑ Nalunl ❑ ,I-..I ❑ H-lin ❑..101. ❑ Pmelllellen 1:1 ni..ned°
❑ YE6 ONO
J 123. PLACE OF INJURY (B.p., home, elnelr1111an ells, weeded Brea, 111.)
O
VT
124. DESCRIBE HOW I1!JURY OCCURRED IE,enle WOO -141d In INury) _
Z
0¢ 125. LOCATION OF INJURY (Blreet OM number, of 1-11m, end d1y, eM 21P)
O
128. SIGNATURE OF CORONER/ DEPUTY CORONER 127. DATE mMldld/Orypy p 126. TYPE NAME. TITLE OF CORONERI DEPUTY CORONER I
REGISTRAR A S C 0 E IIIIIIIIIIIIIIIII MITI IIIII1IIIIIIINIIIp IIIII IIIIIIIIII IIIII IIIIIIIIIIIIIIIIIIIIIII FAx AUTH.I IIIIII-VIII VIII VIII VIIIIIIIIII STATE I •012007000674761• 9 6 3 O 5,0
MINI s is a true
certifi
ed co aEPE RE A Ty Del artment of Public Heal h hbears the filed trazhs si nature m m le~nk.s
0~6t&/Aaff A1.11 212007
DATE ISSUED lc
A ~pp,0 m 1, f it
OFD Director of Public Health add Registrar
j • PBNCOIS.)JINU This copy not valid unless prepared on engraved border displaying seal and signature of Registrar. ~~i a