HomeMy WebLinkAbout948631Betty J. Glover
4539 South 1800 West #107
Roy, UT 84067 C400687
STATE OF UTAH )
COUNTY OF WEBER )
AFFIDAVIT OF BETTY J. GLOVER
ss.
BETTY J. GLOVER, being first duly sworn on an oath, deposes and says that she was
well and personally acquainted with MAX B. GLOVER, one of the Grantees in the deed for the
property located at 4539 South 1800 West #107, Roy, Utah, recorded in the records of Weber
County, Utah, that she was married to said Max B. Glover and that he is the same person as the
Max B. Glover whose death certificate is attached hereto, that by reason of said death, the joint
tenancy on the herinafter described premises has terminated.
PROPERTY DESCRIPTION:
PLOT 9, LOT 45 STAR VALLEY RANCH THAYNE, WYOMING, AND ALL
ATTACHMENTS AND FURNISHINGS LEFT ON OR IN SAID PROPERTY BY
ORIGINAL INVESTOR.
Land Serial No.
Dated this 7-h day of April 2007.
BETTY J. GL , Affiant
On this ~2 7 /h day of April 2007 personally appeared before me Betty J. Glover, the
signer of the within instrument, who duly acla-iowledged to me that she executed the same.
RAMONA R MANN
NOTARY PUBLICITATE OF UIAH
O 5998 South 3100 West OTARY PUBL C
Roy, UT 84067
COMM. EXP. 06.11-10
RECEIVED 7/30/2009 at 9:56 AM
RECEIVING # 948631
BOOK: 728 PAGE: 687
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Ise.-.~\~~t~■■7~'~<~J~■■■~/~~w~■~En
A«e.a blrilwmallM en STATE OF UTAH - DEPARTMENT OF HEALTH r\
IM Vital hciatka Ad
Are'°""SNlis CERTIFICATE OF DEATH
aM Pubs.
LOCAL FILE NIIMBFR. 90.`9/. n'_O k. -
1. NAME OF DECEDENT FIRST MIDDLE LAST 2. SEX J
3a. DATE OF DEATH (Mo. Day- Yr) b. TIME OF DEATH 12a nr. Noce)
Max Bertrum GLOVER ale
Februarv 26. 1995 1000
4 DATE OF BIRTH (W. Dar. Yr.)
5. AGE•Rssl &nMayl
IF UNDEn t YEAn
IF UNDER 241qun9
6. BIRTHPLACE (Gaya Sww mEmege cowaq)
7. SOCIAL SECURITY NUMBER
March 21, 1921
73 v„
on a ey=
no as
n
LPwigt
Ut
h
,
o
a
Ba. PLACE OF DEATH (Check only orrel 6b. NAME OF HOSPITAL, NURSING HOME OR OTHER FACILITY (Il oulside If /acifiry.
HOSPITAL:
O
give sheaf address or location)
~I
--II
❑Inpallenl ❑ERIC)
alien ❑DOA - LlNurslh Home ®Residence ❑Other 4539 South 1800 West, #107
DECEDENT
LOC
ec. ,CITY, TOWN OR ATION OF DEATH - fitl. COUNTY OF DEATH 9. SURVIVING SPOUSE (d wile, give maklen name)
Rov Weber Bett J. McElhenie
f0. WAS DECEDENT I I. MARITAL STATUS' 12a. DECEDENTS USUAL OCCUPATION (Gwe kind of work done 125. KIND OF BUSINESS OR INDUSTRY
EVER IN U S durng most of wmhg 01e. Do NOT use retired)
r
p
ARMEDFOR ❑
CES7
Nevar Manied
':.I
,
al Married
IN Yeq . ❑ No ❑ Owmced Q Widowed Oual i ty Control Analyst ill Air Force Base
T3a. RESIDENCE STREET AND NUMBER
tab. CITY, TOWN, OR COMMUNITY 13a COUNTY
t3d. STATE:
4539 South 1800 West h07 -
Roy Weber
Utah
-13e, INSIDE CITY
LIMITS?
131 7.IP CODE
t4. WAS DECEDENT OF HISPANIC ORIGIN? 101 Yes No
15. RACE - Black, White. Am. [Mien
16. EDUCATION 5 Ipha P
(pedy only h s1 a
84067
(Ifyes; speclly)
~
Trl
( be may beentered/, Japanese.
el.. (spe~iry)
cronpblolle edJ Elementary a Secondary
ge (1]-16 or 17.)
Yes L1 No
71
1F
11 Mexican Q Cuban ❑ Puerto Rican ❑ Other (Sped(y)
White
12 -
PARENTS
17. F THER'S NAME (Flrel, idle, lase -
1, 1
tB. MAIDEN NAME OF OTHER (Flrsi. Middle. Last)
Eldouras Bertrum Glover
Florence Boman
19. NAME.. RFLAI IONSHIP ANU -AILING ADDRESS OF INFO A T
INFORMANT
Betty J. Glover (wife) °4539 South 1800 West. #107 Roy, Utah 84067
20 1E TROD OF DISPOSITON
D
❑
21a. DATE OF DISPOSI ION
21b. PLACE OF OISPOSITION(Name of cemetery
crematory
or other place)
21c. LOCATIO -City or Town; Slate
DISPOSITION
E] plhm
En en,bmenl
,
Ddnallori
Burial ❑ Ciemell.rl. ❑ nemo al
March 2,1995
.
Roy City Cemetery
Roy, Utah
Z
44 -NA I URE OFF FUNERAL SERVICE LISEE
23. LICENSEE NUMBER
24. FUNERAL HOME (Name. address and license number)
515
Myers Mortuary
J
25. ATTEDATE DNDED E BY CECEASEDRTWASIFYING LAST PHYSICIAN
26. 11 not ce"Itrid by medical examiner, was death reported to M
? ❑ Yes ON.
E
.
5865 South. 1900 Wept -
U
C
7--ZI`S5
.
.
11 yea, solar the dale end hour repoded: M,E. Case Na.
Roy, I_(tah 84067
#804
CERTIFIER
27a. G IFIFH
HOUR M0. DAY YEAR
f
$TIFYINC,
,PH
YSICIAN
~G
c
.
~
_
TD the best o my knowledge, death occurred at the lime, date, and place, and due to the cause(s) and manner as stated
°
L
❑ M DI AL EXAMINER) LAW ENFOR n FNT OFFI IA
U
On the basis of aminallon and/or invesll ation in m o anion death occurred at the time, dale lace and due to the causes and manner as stated.
27o SIGNATURE AND TITLE F$71FIER
27
I
c. L
CENSE NUMBER 27d. DATE SI NED (MO.. Day, Yr.)
/
d
~
up
v
'
Z .fr.b.
12 ito
ZR. NAME AND A SS PERSON WHO ERTIFIED THE CAUSE OF DEATH (ITEM 31) (Typeprlm) 0 .S Q
Leslye Ingersoll M.D. 5475 South 500 Fast, Callen, Utah
2B: RF OIS TRARS SIGNAL UFlE
REGISTRAR
30. DATE FILED,(Month„Day, Year)
HAR 01 1995
-
311 PART 1 ENTER THE DISEASES. INJURI H COMPLICA ION THAT CAUSED THE DEATH. DO NOT ENTEq THE MOO OF DYIN ,SUCH CARDIAC Appmzlmale-Imervel
OR RESPIRATORY ARREST, SHOCK, O FAOF FAILURE. T ONLY ONE CAUSE ON EACH LINE
. Be tweed. Onset And'.
IMMEDIATE CAUSE (Final I -0ealh.
disease or deaf hon . (',Q f~(~ ' ,r
resulting In death) e 3 _
DUETOIOnASACONSEOUENC1
1:
SequenliAllyy list condlllDns. a _ yy,,,~Aaaas{laµ,. /ZC1A(19`Cr G(I] /t'1LIR5/7~fG
It any, load ng to Immediate OUE MOS ASACC OUENCE
OFI
.
cause. Enter
UNDERLYING / -
AUSE OF
.
CAUSE (disease or injury
C Lb ) 7~f
that fndevents resullin C(l~ Sitd _G-1. /01 43 ,SJl.Ggr (r [L '
1--- - _
In death) LAST g .DYE Tp ion as A cpN5E0UENCE Oq:
DEATH
U
V
PART II. Other SlpnIFi .l Cnndiu s conlrlbullno Io death but.nol 32. IN YOUR OPINION, TOBACCO USE BY THE DECEDENT -33a. WAS
eslllrg M theondorl IN usa ql en In Pan 7
WERE AUTOPSY
Iot
AUTOPSY DINGS AVARABLE0 Probably conbib.led use o1 death PERFORMORTO COMPLETION
----0 Was the underlying cause o1 death -
t
6
AUSE OF DEATH?
❑ Dld ot contribute Io the cause of tlealh
0 Is unknown In r
t
YesYe
il
h
❑ N
e
a
to
s .
o
of dea-USER
34. MANNER OF DEA rH 35a. DATE OF INJURY 355. TIME OF INJURY 35c. INJURY AT WORK? 35d. PLACE OF INJURY-AI home farm, sheet. factory
,
❑ (Month, bay, Year) (74 HOUr Clock/ office
~
JaNr
l
buildin
BI
S
l
1
(
,
a
pea
Attidanl
G, (
yJ
g.
Yes N~
❑ Suicide ❑ H
ml
35e.LOCATION (Sterer or rural mule number, aTyorlown, countyands(ale)
35 IF moiorvehlcle accident. s
c. pe.dy it decadent was,
o
dde
driver, pa...eget or pedestrian,
❑ Urxlelerminetl ❑ Pendin
351. DESCrtrOF 14OW.INJURY OCCURRED (enter sequence of events which resulted In injury, NATURE OF INJURY SHOULD BE ENTERED IN ITEM 311
g
It Injured ImesllBAllon
- -
AccldanlAlly
'
U
DH BVRHS•FOrm 12. Rev. f-1.119
This is to certify that this is a true copy of the certificate on. file in this office. This certified copy is issued
under authority of section 26.2-22 of the Utah Code Annotated, 1953 As Amended.
rn Jr Irl
S Date Issued:
177a ,
MAR
00
z: County 6 B 1~ John E. Brockert
I 47
m y DIRECTOR OF VITAL STATISTICS ~kk'~ peU r r
Registrar W By
; a
~C * ~ 1
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