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AFFIDAVIT OF SURVIVORSHIP
I, DOROTHY G. ALLSOP, being duly sworn under oath, state as follows:
1. That Harold C. Allsop has tenancy by the entireties with me in land in Lincoln
County, Wyoming, more particularly described as follows:
Plat Thirteen (13) Lot Forty-Two (42) in Star Valley Ranch, as platted and
recorded in the official records of Lincoln County, Wyoming.
Together with all improvements and appurtenances thereon.
Attached hereto is a copy of the Warranty Deed creating the tenancy by the entireties, recorded
in the Lincoln County, Wyoming, land records in Book 443 PR at Page 517 on April 3, 2000 as
Instrument No. 865030.
2. That I, Dorothy G. Allsop, the surviving spouse of Harold C. Allsop, hereby
certify that Harold C. Allsop died on September 28, 2009. Attached hereto is an original copy of
the Certificate of Death issued for Harold C. Allsop.
3. That pursuant to Wyoming Statutes § 2-9-102, I certify that the tenancy of Harold
C. Allsop has been terminated by his death, and that title to the above-referenced land is now in
the name of Dorothy G. Allsop, a single woman.
DATED this _a day of October, 2009.
RECEIVED 10115/2009 at 10:08 AM
RECEIVING # 950053
BOOK: 734 PAGE:8
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
DOROTHY ~4LLSOP
STATE OF WYOMING )
) SS.
COUNTY OF LINCOLN )
SUBSCRIBED AND SWORN TO before me by DOROTHY G. ALLSOP this
day of October, 2009.
WITNESS my hand and official seal.
M. KEVIN VOYLES - NOTARY PUBLIC
COUNTY OF 4 V- STATE OF
LINCOLN WYOMING
MY COMMISSION EXPIRES JULY 16, 2011
My Commission expires: 07 !6 II
OCT. 5.2005 2:39PM LINCOLN CO CLERK "`T10.471--P.5
WARRAD1T7C DEED
Michael Roberts and Pamela T. 0011 009
husband and wife Roberts
grantors,. for and in consideration of TEN ($10.00) DOLLARS and
other Good and Valuable Considerations in hand paid, receipt
whereof is hereby acknowledged, CONVEX AND WARRANT TO:
Harold C. Allsop and Dorothy G. Allsop
husband and wife
grantee, whose mailing address is P.O. Box 971, Thayne, WY 83127,
the following described real estate situate in Lincoln County
and State of Wyoming, hereby releasing and waiving all rights'
under and by virtue of the homestead exemption laws of the State'
to-wit:
Plat Thirteen (13) Lot Forty-Two (42) in Star Valley
Ranch, as platted and recorded in the official records
of Lincoln County, Wyoming
SUBJECT, however, to all restrictions, reservations,
easements and rights-of-way of record or in use.
WITNESS our hands this day,of March, 2000.
chael' oberts
Pamela Y. Roberts i r
State of Wyoming )
County of Natrona ) ss.
The foregoing instrument was acknowledged before me, a notary
public in and for said county and state, bichael Roberts
and Pamela I. Roberts, husband and wife, this day of March,
2000.
Witness my hand and Official Seal.
~ju n~L~: ~Totazy Public
Expires: -7 -20 oO
865030 -INCor h6ECF r ED .
04 APR -3 9! 11.3
73003 517 KEIyM~~~R WYDM►Q
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MOW
M h. CERTIFICATE OF DEATH'S
State File Number: 2009023494
/ Harold Corbett Allso
DECEDENT INFORMATION i
Date of Death: September 28, 2009 Time of Death: 06150
\ City of Death:' Sot Lake City County of Death: Salt Lake>
;Age: 83 Date of Birth: December 11, 1925
Place of Birth: Buhl, Idaho Sex;" Male
Armed` Services: Yes Marital Status: Married
Spouse's Name: Dorothy Grimes Usual Occupation: Pharmacist
Industry/Business: Pharmacy Education: Bachelor's Degree
Residence:' Star Valley Ranch, Wyoming Father's Name: Albert Allsop
Mother's Name: Emily,Ray Corbett Facility Type: Hospital Inpatient
Facility or Address: Huntsman Cancer Hospital
INFORMANT INFORMATION
Name: Dorothy Allsop Relationship: Wife
Mailing Address: PO Box 971, Thayne, Wyoming 83127
DISPOSITION INFORMATION
Method of Disposition: Burial/Removal
Place of Disposition: Grace Cemetery, Grace, Idaho
Date of Disposition: October 1, 2009
FUNERALHOME INFORMATION
' Funeral Home: Goff Mortuary
Address: 8090 South State, Midvale, Utah 84047
Funeral Director: Del Ballard
MEDICAL CERTIFICATION
{ Medical Professional: John H Ward MD, 2000 Circle of Hope, Salt Lake City, Utah 84112
CAUSE' bF DEATH
s, metastatic malignant melanoma [Onset: 3 Months]
Tobacco Use: Non-user
Medical Examiner Contacted: Yes Autopsy Performed: No Manner of Death: Natural
I,
Date 'Issued: September 29, 2009 j
i,
1. This is an exact reproduction of the document registered in the State Office of Vital Statistics.
r
Security features ofthis official document include: Intaglio BOMer,,V & R images. in top cyeloids,
ultra violet fibers document d splays the date seal and s g ature of`theState Registrar and the County/Dstr ct/tHealth Officer.
IIIII~IIIIIII~IIIIIIIIIIII~IIIIIIIILIII~IIII~II eiZEdwards
*06251,0394*,
1.47 q Barry E. Nangle, State Registrar Director/Health Officer
i
Office of Vital Statistics County/District Health De rtment i gl~ e b y `I