HomeMy WebLinkAbout948783RECEIVED 8/5/2009 at - I
RECEIVING # 948783
BOOK: 729 PAGE: 299
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT 00699
O O
I, Dickie R. White, being duly sworn upon my oath depose and state as follows:
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1. That I am a Successor Trustee named in the White Family Trust dated September
U G) ~
4, 1992.
E" 2. That on September 4, 1992 in Book 315PR on page 111 of records of Lincoln
a County Clerk was recorded a QuitClaim Deed from Ralph V. White and Caroline
J. White and Ralph V. White and Caroline J. White, as Trustees of the White
Family Trust conveying the following described land:
The South 15 feet of Lot 4 Block E, Riverview Addition to Tulsa, Lincoln
County, Wyoming as described on the official plat thereof.
3. The QuitClaim Deed conveying the property to the trust was not properly defined
as required by W. S. 34-2-122 (1977) in that the date of the Trust was not shown.
The date of the Trust is September 4, 1992.
4. Ralph V. White died on Pursuant to W.S. 34-2-
123 (1977) and according to the terms of the Trust, successor trustee is Dickie R.
White of 219 S. Jones Avenue, Rangely, Colorado 81648. Attached is a copy of
the original certificate of death, certified to as trust and correct by public authority
in which the original of said certificate is a matter of record, is attached hereto as
Exhibit "A". Affiant is lawfully serving in capacity of successor trustee.
Caroline J. White died on ~-77 1 1 , p (2 . Pursuant to W.S.
34-2-123 (1977) and according to the to s of the Trust, successor trustee is
Dickie R. White of 219 S. Jones Avenue, Rangely, Colorado 81648. Attached is a
copy of the original certificate of death, certified to as trust and correct by public
authority in which the original of said certificate is a matter of record, is attached
hereto as Exhibit "B". Affiant is lawfully serving in capacity of successor trustee.
Dated this day of 2009
Z t1 d A/
Dickie R. White, Successor Trustee
State of Colorado
County of Rio Blanco
I, Dickie R. White, do solemnly swear that I have read the foregoing Affidavit
subscribed by me; that I know the contents thereof and verily believe the statements
therein contained are true.
Dickie R. White, Successor Trustee
The foregoing instrument was subscribed and sworn before me by Dickie R. WJte,
Successor Trustee of the White Family Trust dated September 4, 1992 this
day 2009
W s my haN' and official seal.
BRIELLE I..
CARLSON
a
Notary Public
MY xpires: 07/08/2013
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STATEOF COLORADO
COLORADO DEPARTMENT; OF>PUBLIGHEALTH AND ENVIRONMENT
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HOLD TO LIGHT To VIEW WATERMARK
STATE OF COLORADO
CERTIFICATE O>F DEATH STATE FILE NUMBER ~
0~(3UU
a a
1. Utctutrl I'S NAME (First, Middle, Lest) 2: SEX
3. DATE OF DEATH(MOnfh, Day; year)
Ralph V.-WHITE
Male
..July 17, 2008.
- 4. SOCIAL SECU ITY Se. AGE-Last SD UNDERI YEAR 5c UNDERI DAV (DATE OFBT
!R
1
NUMBER Btnhday (Years)
7. BIRTHPLACE (Co and State or Foreign
Mos. Days His (Mina (Month, De "
79
Country)
Mar 19, 1929
Thayne WY
9. WAS DECEDENT EVER IN
PLACE OF TH ' ec nl one),
-
C
ARMED FORCES? HOSPITAL
®YSS ❑ No : -
Inpatient ERIOUtpe(ient CI DOA
OTyER: 1
U Nursing HOfne 0 Ree'dence ':19 Omer(Specify) A9sisted: Living
FACILITY NAME (If not minfru(ton, give street end number)
9c. CITY, TOWN, OR LOCATION OF DEATH. 911. COUNTY OF DEATH
The Oaks
Fruita Mesa
10a. DECEDENTS USUAL OCCUPATION.'
'(Give kind of work:done during: most of working tire
10b, KIND OF BUSINESSfINDUSTRY'
11. MARITAL SYATUS Mertietl,
12, SPOUSE (tl wife, give ma/den'name)
.
Do at use.tedrad):
Neber MeniedWidowed,
OiVOced (Spedlfy)
Senior Meter Tech
Gas Company
Widowed
Carolina J
P ohl
138. RESIDENCE -STATE
136. COUNTY
13c. CITI', TOWN OR LOCATION '
.
13d STREET AND NUMBER..
CO
Mesa
Fruita
B05 '4t. Ottle
13e: INSIDE
CITY
73f ZIP COD
E
11A_1
DECCDENT OF HISPANIC ORIGIN?
if
No or Y
- I!
1b RACE--Amencen lndion\
16. DECEDENTS'EDUCATION(Speclfy only highest
LIMITS?
=
y
es
yea speclly Cuban,
R can tc)
Black,. VJllde, etc (Spetly)
ggratle COmppl.I- Elementary or secondary
h 12
ll
C
13
Ig Yes
N oyes
g
)
o
ege (
1hr0uph 16 or 17+)
O"°
8152
White
14
17. FATHER-NAME .'(First, Middle, Lad) 18 MOTHER~NAME (fuss, Middle, LaV(Melds,), 19. INB J RMANT-NAME and relationship to decreased.
Orlan"Alma .Whate Laura Bell Swenson Dickie R. White-Son
20a. METHOD OF DISPOSITION 200, PLACE OF DISPOStTION(Name ul cemeterycrematory, 0 20c 1- CATION-City, Town, Stele
• Burial otherplecal.. .
❑-Cremellon no Removal from Stale .
❑Don.. ion q Other(speaty) Viola Cemete La .3arga:, WY
214. SIGNATURE OF FUNERAL DIRECTOR ORPERSON ACTINGAS 5UCH . 21 b. NAME AND ADDRESS OF FACILITY:'
' Snell-McLean d
Home,LLC
,
729 37 3/10 Road.,. ,
1
Q~ 1
.
1
PCO zip'81526?
22e; EGISTRAR' SIGNATURE
22b. DATE FILED (Month, Day, Year):
23.'TIME EAT 24, DATE PRONOUNCED DEAD ABC O ER NOTIFIED?
Month - Day Yea,
Hdur (Yes.tlr o) '
4;0511P M Jul 17 2008 405 PM - No
TO.BE COMPLETED O 6Y:GERTIFYING PHYSICIAN
''--TO BE COMPLETED BY CORONER
2e. To laa seal f hn etl 6s, death oaeumU al I a 1 e, date .ne plecn, eM Jun w
Ina Gues(s) .;m m Nalea
c ins...Is ar s......lbn aMl.r Inva,lipatl.n. In my oplnlan Oaatn 9-d al IM
ee
ls and p ace, eM aue to the uuee(.) uM manner ae stelae.
Signature'-
Sqnblurd
1
20.E DATE SIGNE (M Ih, Day, Year)
29 DATE 5IC,NED (Manlh, Day , .Year)
_
30. NAME, TITLE.AND. ILI ADDRE
SS F CERTIFIER/CORONER (T e/PrIM
4:_
5.
Michael Hughes,, M.D.: 281 :North;Pluin Truita, C0' zip' 81521:
31. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type/Print)
.32. MANNEROF'DEATH - 33a. DATE:OFINJURY 33b. TIME'OF. 33c. INJURY AT 33d:'D.EBCRIBE`HOW INJURY OCCU..RED
PeadI.e (Month, Day, Year) INJURY!? WORK?
~Nelerel:: ❑ ' ' -
Ipvealip non
UmIslmmined M
Manner 9u1dda 33e. PLldinp si INJURY -y) t home, fans, •ireel; factory office 33f. LOCATION (Street and Number or Rural Route Number, City, County, Slate)
❑ Homicide
•
PART 34.; IMMEDIATE CAUSE (ENTER 0 Y ONE CAUSE PER LINE FV
b), I. not ~nler made of (lying,a g.Coroiac or Respiratory Arrest)
imersl balweea-.]
ea
L
D J/
I (a)
a
death
CONDITIONS DUE TO OR AS A CONSEQUENCE OF
IF ANY WHICH
n em e n onset
GAVE RISE TO
:
(b
.nd a..tn
IMMEDIATE CAUSE:
STATING THE `;DUE TO OR AS A CONSEQUENCE OF
marvel eeMasn Dose
NG CAUSE -
UNOERLY (C)
-
.
:
nddestn
LAST (c)
PART OTHER SIGNIFICANT CONDITIONS-Condillons contributing to death but not reletad'to cause in
II PART I (e
g
alcohol ab
b
it
35. AUTOPSY
F YE d
S were findings abnsideretl
38. i
i'
.
use;: o
es
y, smoker);:
(Yes or No)
.l
n
determinlnp causeof death?
JUL 2 2 2000
DATE ISSUED
RONALD
S. HYMAN:>
THIS IS A TRUE CERTIFICATION OF NAME AND FACTS AS
,
STATE REGISTRAR
f
RECORDED IN THIS OFFICE. Do not accept unless prepared on
security paper with
der displaymg the Colorado state seal
I
$
Regis
and signature of the Registrar. . P PENALTY BY L #W, 2S 2.118
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Colorado Revised Statutes, 1982, if a person alters uses, attempts io-
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use or furnishes to another for deceptive use any vital statistics record.
0 0 3 3 8 0 0 3 8
'
NOT VALID IF,?HOTOCOPIED
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REV 07706
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