HomeMy WebLinkAbout947390AFFIDAVIT OF SURVIVORSHIP
STATE OF WYOMING )
) ss. 0Ou" S28
COUNTY OF LINCOLN )
I, ALICE J. GAULT, being of legal age and first duly sworn, deposes and says as follows:
1. That Johnnie Edward Gault, the decedent mentioned in the attached certified copy of the
certificate of death, is the same person as Johnnie E. Gault named as one of the parties in that
certain Warranty Deed dated March 30, 1978, executed by Alice J. Gault, also known as
Alice J. Bohannon to Alice J. Gault and Johnnie E. Gault, husband and wife as tenants by
the entireties with right of survivorship, recorded as Instrument Number 506116, on March
30, 1978, in Book 144PR at Page 678, 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:
A portion of the Northeast Quarter of the Northwest Quarter
(NE1/4NW1/4) of Section 7, Township 26 North, Range 112 West of
the 6`h Principal Meridian, Lincoln County, Wyoming and more
particularly described as follows, to-wit:
BEGINNING at a point that is S27°05'W, 736.2 feet from the North
one quarter corner of said Section 7 where is found a 2" diameter
galvanized steel pipe with brass cap inscribed "U.S. DEPT. OF THE
INTERIOR BUREAU OF LAND MANAGEMENT Unlawful to
Disturb Cadastral Survey
7
T26N R1 12W
1 S6
4 S7 1962"
over a granite stone 18"x12"x15" marked 1/4 on N. Face, SS on S.
Face, with a mound of stone to the S; thence S 14'2 PE, 100.2 feet to
a point on the northerly right-of-way line of the Calpet Secondary
Highway; thence S75°39'W, 89.8 feet along said line to a point,
thence N14°21'W, 100.0 feet to a point; thence N75 °31'E, 90.0 feet
to the point of beginning; each point being marked by a steel T-
shaped stake 24" long with brass cap inscribed "Survey Point, Do Not
Disburb RLS 164"; containing an area of 0.21 acre, more or less; all
in accordance with the map prepared and filed for record in the Office
of the Cleric of Lincoln County.
2. That I am the same Alice J. Gault mentioned in the above referenced Deed and thereby am
a person interested in the effective property or the title thereto and pursuant to § 2-9-102
W.S. (1980) hereby make the death a matter of record and certify that upon the death of
Johnnie E. Gault, his previous estate in the property was terminated.
RECEIVED 5/27/2009 at 2:25 PM
RECEIVING # 947390
BOOK: 723 PAGE: 828
JEANNE WAGNER
NCOLN COUNTY CLERK, KEMMEPFR WY
0 04829
3. That the certified copy of the certificate of death indicates that Johnnie E. Gault died on April
7, 2009 in Salt Lake City, Salt Lake County, Utah.
Dated this Z I day of WIX--.(1- 92009.
11
STATE OF WYOMING )
) ss.
COUNTY OF ( Ili c oh7 )
ALICE J. 'AULT
Subscribed and sworn to before me by Alice J. Gault, this X17 f-" day of r, ~
2009.
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CERTIFICATE OF DEATH
_ ;'State File Number: 2009016624
Johnnie Edward Gault DECEDENT INFORMATION I
Date)of Death: April 7, 2009
Time of Death:
00:25
City of Death: Salt Lake City
County of Death:
Salt Lake
Age: 79
Date of Birth:
October 31, 1
929
Place of Birth: Mendota, Missouri
Sex:
1
Male
Armed Services: Yes
Marital Status:
Married
Spouse's Name: Alice J Anelli
Usual Occupation:
Truck Driver
Industry/Business: Trucking
Education:
High School or GED
Residence: LaBarge, Wyoming
Father's Name:
Edward Jacob Gault
Mother's Name: Zelma Ethel Haines
Facility Type:
Hospital Inpatient \
Facility or Address: Veteran's Affairs Medical Center.
INFORMANT INFORMATION
Name: Alice-J Gault
Relationship:
Spouse
Mailing Address: P.O. Box 417, LaBarge, Wyoming.83123 `
DISPOSITION INFORMATION X
Method of Disposition: Cremation
Place of Disposition: Utah Funeral Directors Cremation. Center, South Jordan,
Utah
Date of Disposition: April 9, 2009"
-
FUNERAL HOME INFORMATION
Funeral Home: i Jenkins-Soffe Mortuary -Murray
Address: 4760 South State Street; Salt Lake
City; Utah 84107-
` -
Funeral Director: Roger 'K Wilcox .
MEDICAL CERTIFICATION
Certifying Physician:, Peter M Yarbrough MD, 500 Foothi
ll Drive, Salt Lake City, Utah 84148
CAUSE OF DEATH I
Septic Shock [Onset: 12 Hours],
Colitis [Onset: 5 Days]
_
Kidney Disease, Coronary Artery Disease
Tobacco Use: Unknown
i
Medical Examiner Contacted. No Autopsy Performed: Yes
Autopsy Available: No Manner of Death: Natural
Date Issued: April 9, 2009
This is an exact reproduction of the document registered in the State Office of Vital Statistics.
Security features of this official document include: Intaglio Border, V & R images in top cycloids,
ultra violet fibers and hologram image of the Utah State Seal, over the words "State of Utah". This
document displays the date, seal and-signature of the State Registrar and the County/District Health Officer.
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Barry E. Nangle, State Registrar Director/Health Officer
' Office of Vital Statistics, County/District Health Department
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