HomeMy WebLinkAbout949072STATE OF WYOMING )
) ss.
COUNTY OF LINCOLN )
AFFIDAVIT OF SURVIVORSHIP
I, DENNIS JOHNSON, being first duly sworn, and upon oath,
deposes and states as follows:
00040±
1. I am the son of the decedent Gene Walton Johnson and Affiant herein
and am of adult age.
2. On or about the 24th day of November, 1998, my mother, Gene
Walton Johnson died, as is evidenced by the official Certificate of Death attached
hereto as Exhibit "A".
3. At the time of my mother's death, she had certain real/personal
property, said real/personal property being located in the County of Lincoln, State
of Wyoming, and more particularly described as follows:
1986 Dodge Pickup VIN 1B7HW14W4GS040618
4. By reason of the death of said GENE WALTON JOHNSON, her
interest and title in said real/personal property has terminated and title to the
real/personal property has vested in DENNIS JOHNSON.
FURTHER AFFIANT SAYETH NOT.
DATED this day of, 2009.
Dennis Johnson
RECEIVED 8/24/2009 at 12:03 PM
RECEIVING # 949072
BOOK: 730 PAGE: 401
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Affidavit of Survivorship
Estate of Gene Walton Johnson
Page 1 of 2
STATE OF WYOMING )
) ss.
COUNTY OF LINCOLN )
U'064U
On the -R-l day of & n(LIJ- , 2009 before me personally appeared
DENNIS JOHNSON, being firs my sworn by me upon his oath says that the
facts alleged in the foregoing ins rument are true. Witness my hand and official
seal.
JAMIE M. JENKINS - NOTARY PUBLIC
9A State
County of ((i~a~~~
Lincoln Wyor
My Commission Expires May 19,
My Commission Expires:
Affidavit of Survivorship
Estate of Gene Walton Johnson
Page 2 of 2
W I'h1fv yr ~ v+•:jl-----------'--- - - - - - _ - - - - - - - \ r 6-
ry Y @@
.A',% N. LIS;rA- II - ~
STATE OF WYOMING W WTI
y DEPARTMENT OF HEALTH 1000403 '
STATE OF WYOMING
DEPARTMENT OF HEALTH u,
LOCAL FILE, UMBER CERTIFICATE OF DEATH STATE FIE NUMBER
TYPE 1. DECEDENT-NAME FIRST MIDDLE LAST 2. SEX 3. DATE OF.DEATH (Mo, Dry, W-)
OR PRINT.
IN GENE WALTON JOHNSON FEMALE' NOVEMBER 24, 1998
PERMANENT
ae( SOCIAL SECURITY NUMDFw W. AGE-Last SWIM" 5D. UNDER iYEAR - Sc. UNDER 1 DAY 6. DATE OF BIRTH (Aim, Dry, W.)
RANK
FOR (y`%I`a). 81 Momma o.r. Heum 141A" MAY .27, 1917
INSTRUCTIONS
SEE 7a PLACE OF DEATH (Check wry'.onsl
HANDBOOK
IIDSq A~ ❑ bgalient ❑ ER/ Outpatient ❑ DOA 19,ni. Foos ❑ Rssid- 0 OIMr (Spec6y)
7b. FACILITY NAME (N not bud9Mon,. gie:idn" ald nlnWer) - - 7c. CITY, TOWN. OR LOCA71ON. OF DEATH COUNTY OF DEATH
STAR VALLEY CARE CENTER AFTON LINCOLN
6. STATE OF MATH IN not In USA., rams cm1Wy). 9. MARRIED. NEVER MARRIED, 10. SURVIVING SPOUSE (11 mile. ktl ;iWbon name)
WYOMING WIDOWED, DvoRCED rsaaGrr)
WIDOWED
It. WAS DECEDENT EVER IN U.S. ARMED FORCES? 12a. USUAL OCCUPATION fGhe kind of W&* done d-9 most 12b. KIND OF BUSINESS OR INDUSTRY
(Spwxy yes a ro) NO - d IUUd[hD a.. ewn M`Mhedl
HOUSEWIFE HOME MAKING
13e. RESIDENCE - STATE: 93b. WUNTY ° 13c. CRY,; TOWN OR LOCATION 113d-311111 T A111111111,11101
WYOMING LINCOLN AUBURN 2360 STATE HIGHWAY 238
13e. INSIDE CITY LMTIE? la. WAS DECEOENT OF HISPANICOH4IN? 16, RAGE' 11-6- Indian, 16. DSCEDEWF'S EDUCATION
Mealy Yea a M) I-- Ye. y 6 Yea, M dfv Beck. WNb, En. ISpeWY orgy. Jiprest pads ooepANOO)
CuberL Maaken, Puerto Rican, Eio.) (Spedly) NO WHITE EkxnenayiSeaderr w-121cd a (1-4ws+)
No7 Yee❑(SpeG(y( - 12 _
I T. FATHER'S NAME Finn MkWe Last 16. MOTHER'S NAME Fim MEdb Malden Swname
WILLIAM WALTONLEAH HURD
' j.. 19a. INFORMANT-NAME (Typo w Print) 194 RELATIONSHIP TO DECEDENT
LA VADA OLSEN DAUGHTER
•
19c. MAILING ADDRESS STREET OR R.F.D. NUMBER CRY OR TOWN STATE ZIP CODE
51TOMS 'CANYON ROAD AUBURN WYOMING 83111
20L BInIaL cremation, Removal n111 DATE (AA1.y Day. WU 200. CEMETERY OR CREMATORY-NAME 20d. LOCATION CITY OR TOWN STATE
kom State. DOW (Spsdiy).
OVEMBER 28 1998 AUBURN CEMETERY AUBURN. WYOMING
e • • 211. NERAI: BE E Pathan ACtkq Number 21b. NAME OF FACILRY Number 21c. ADDRESS OF FACILITY'.:.
Such
► _ _ SCHWAB MORTUARY 45 44, EAST FOURTH AVE., AFTON
22s. 0 the beat my~wowrdge, -read am d1e*, aM 2 1 On Ins d albn ..N/w Imroe%,ti n, my NCn death warred
Z 10 the _me(.)alatad at the I=d ale aM place nlv] due to the cause(s) pabQ
(SWA&_ erd'TWO) ► / w (so.& e W cave) ►
y 220. DATE SGNED (Ab 22c. HOUR OF DEATH 23b. DATE SIGNED (Ma, DRY, Yr.) 230. HOUR OF DEATH
i~ /k-6 2:10 A. M o M
$ 22d. NAME OF ATTENDING PWSICIAN IF OTHER THAN CERTIFIER (Type or Aka) $8 23d. PRONOUNCED DEAD (MO.. 0". riJ 239. PRONOUNCED DEAD (Nov)
fo-
iY M
24. NAME AND ADDRESS OFCERTIFIER (PHYSICIAN OR CORONER)(TMe a P")
O. D. PERKES MD. 110 HOSPITAL LANE AFTON WYOMING 83110
2sa. REGISTRAR / 25b. DATE 'RECEIVED -IYY: REGISTRAR (Ma. Day, WJ
PAm I. Enw Ike r9aeesas, iryudes. of that caused death. Do not emsr the node of dyiro. such u eandiac e
ll. w heart Iailum. Usk orgy one cause on each line. Or I " Between
26. w ecry uresL alor
darv ud Death.
MMEDUSE (Fklel //meuakq ) N a Y yC 1
DUE TO [OR AS A CONSEQUENCE OF):
b. +
SegAmusly IOU coI1 KWW DUE TO (OR AS A CONSEQUENCE OFI: I /r
V any, leading to Lmllediale 1
I
caws Enter UNDERLYING
CAUSE IOlaaase w Wary DUE TO (OR A CONSEQUENCE OF):
that initialed etyma 1
r • • meal•ro N death) LAST -
d.
PAIR N. OTHER SIGNIFICANT DONDITK)NS•COndlli0re conklDldklp to death Dut not Mated to cauas given in PART L 27. AUTOPSY lS 26. V" CASE REFERRED TO CORONER
NO Yes w ro (Specify Yea w ro! N
29. MANNER OF DEATH 30a: DATE OF INIURY Y_) 1 TIME Of (Siellidly yes dv 306. 300. Ittu AT WORK?) 30d. DESCRIBE HOW INJURY OCCURRED
(AIarM, Dry,
lute)' ai nwtl p lee.
M
Aoiddamt
30s. PLACE OF INJURY-AI lame. term: abasl. IacWry. 301. LOCATION (Seal[ and Number w Runt RouN Number, Cily'w Town. 8tue1::
: VR 2-99 Suk*ls aco dm9~n,db` pike/ bolding, etc. (SpePMYI
Dete
8/97 T 5M' Homicide
f~~ia t
,m~-~067619
IJ
This is a true and exact reproduction of the document on file in the office of Vital 1
~u.~e~~/"L.a/
Records Services, Cheyenne,. Wyoming.
_ ag e 2 1 '9 WcindaMcCaffTey~
^ DATE ISSUED: Deputy State Registrar
\ y k'
I ((G This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and signature ofthe Deputy State Registrar:Y%
rJr +1
r.
111 M~
IIII I.I.I.I.I.IJ.LLI ~ _~(WHI %("1