HomeMy WebLinkAbout950082AFFIDAVIT OF SURVIVORSHIP
RECEIVED 10/19/2009 at 12:12 PM
RECEIVING # 950082
STATE OF UTAH ) BOOK: 734 PAGE: 124
SS. JEANNE WAGNER
COUNTY OF WEBER ) LINCOLN COUNTY CLERK, KEMMERER, WY
I, Julie Ann Ellis, now known as Julie Andreasen being of lawful age and duly sworn
according to law upon my oath and depose and state:
That I am of adult age, a resident of Harrisville, Utah, and the Affiant herein.
2. That by virtue of the conveyance which is recorded in the Office of the Clerk for Lincoln
County, Wyoming, located at Kemmerer, Wyoming in Book 137PR on page 546 is recorded a
Warranty Deed dated June 26, 1977, which conveys unto John Wayne Ellis and Julie Ann Ellis,
husband and wife as joint tenants, the following property more particularly described, to-wit:
Lot 307 of Lake View Estates Tracts A- F, Lincoln County, Wyoming.
-7 d
3. That said John Wayne Ellis died on the
day of GNUS ~q f , and
a copy of the original certificate of death, certified to an a true and correct by public authority in
which the original of said certificate is a matter of record, is attached hereto as Exhibit "A".
4. That by reason of death of said John Wayne Ellis and by reason of state statutes, the
decedent's interest and title in said property has terminated and title to the real property conveyed
thereby has vested absolutely in Julie Ann Ellis, now known as Julie Andreasen continuously
since the death of the said decedent.
FURTHER AFFIANT SAYETH NOT.
J lie nureasen
The foregoing instrument was subscribed and sworn to before me by Julie Andreasen this
43 day of &Ijeher 2001
Witnessed my hand and official seal.
Notary Public
Commission Expires: "7 " l d 3
JENNIFER E. DECKER
Notary Irt hlir Stem of Utah
r My Commission &pir" onr
Wuii 19, 2013
Comm. NwhWn 07+1739
VQJ
CLERKy ORDER
479
LOCAL FILE NUMBER
DECEDENT - NAME FIRST MIDDLE
MUN I AIVA
• .w_v. rj0%'jA25 '-BIT "A„
,--ACATE OF DEATH
STATE FILE NUMBER
LAST SEX DATE OF DEATH (Mo., Day,
John I Wayne I ELLIS Male Aug, 24,Yr979
2. 3.
1.
RACE-White, Black, American Indian, AGE - Last UNDER 1 YEAR UNDER 1 DAY DATE OF BIRTH (MO., Day, Yr.) COUNTY OF DEATH
etc. (spec"y)u7 ite Birthe4lYears) Mos. Days Hours Min. May 3, 1937 7. Cascade
4 W li 5a. c•F L 5b. 5c. 6. .
street and number) IF HOSP. OR INST. Indicate ODA,
CITY, TOWN, OR LOCATION OF DEATH HOSPITAL OR OTHER INSTITUTION O N uatmi 4.f n°$Oin either. Uth give OP/Emer. RiUrptlent (Specify)
Neihart Kings Hill, t 7d. L~, tt11
s 7b. 7c.
NEVER MARRIED, SURVIVING SPOUSE (It wife, give maiden name)
STATE OF BIRTH (11 not in U.S.A., CITIZEN OF WHAT COUNTRY MARRIED. IV QEP (Spe ify) Julie Ann Krey
Usual Residence name count ry~alif ♦ USA ~ed it.
Where Decedent 6 9. 10'
Lived. It Death WAS DECEDENT EVER IN U. S.
Occurred in SOCIAL SECURITY NUMBER USUAL OCCUPATION (Give kind of work done during KIND OF BUSINESS OR INDUSTRY ARMED FFOORCES (Specify Yes of NO)
most of king life eke it retired
. H.Bllia On 14
Institution, w n DaGUOn cbntractor 13b we
See Handbook 12 13a.
a ATION ( INSIDE CITY LIMITS STREET AND NUMBER : -
I RESIDENCE - STATE COUNTY CITY, TOWN, OR LOCSpecify Yes or No)
v I~ Utah Weber 15c No. Ogden d yes 2731 No. 700., East
A 15a 15b.
MOTHER -MAIDEN NAME FIRST MIDDLE LAST
FATHER -NAME FIRST MIDDLE LAST Edna Thargood
We H. Ellis 17.
1 s.
E :
INFORMANT -NAME (Type or Print) MAILING ADDRESS STREET OR. R.F.D. NO. CITY OR TOWN STATE ZIP
Myers NAM Mortuary 18b 845 Washington Blvd., Ogden, UT 84404
` 1aa.
i CEMETERY OR CREMATORY - NAME LOCATION CITY OR TOWN STATE Utah
Weber Co,,
1 ga. 19b.
BURIAL, CREMATION, REMOVAL, OTHER (Specify) MORTUARY OR OTHER -NAME AND ADDRESS
' 1sc Removal/Burial Croxford & Sons, 1307 en ral, Gt. Falls, MT 59401
20.
• • • License Number
DATE OF DISPOSITION (Month, Day, Vear). ; PERSON IN CHARGE OF POSITION
^85
28
Aug. 27, 1979 22. (Signature)
N z1.
To be Completed by DRONER My death
To be Completed by CERTIFYING PHYSICIAN Only inion
23a. best of my knowledge, death occurred at the time, date and place,and due to the 24a occurred eft t f examination
Te,l d do andd/ er I ndtga to he cause(s) steed.
1
CO ~ causes d.
o t`
m
([f b
r (Sig ture and Title) )0.
(Signature and Title) OF DE H ~f~Pd
i DATE SIGNED (Month, Day. Year) HOUR OF DEATH DATE SIGNED (Month, ay, Year) HOUR
8-27-79 tae. M
a 23b. 23C. M 24b.
~ PRONOUNCED DEAD (MO., Day, Yr.) PRONOUNCED DEAD (Hour)
NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or 8-2679
24a. ON 24e. AT I M
23d.
1 NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONEFj.ff.ype or Print) (,ti.' Falls, MT 59401
R.W.Donovan, Dep. heriff & Coroner, Casc.Co. Crt.Hse.,._. ,
25. DATE RECEIVED BY LOCAL REGI RAR (Mo., Day, Yr.)
LOCAL REGISTR
7 Conditions If
Any Which 26b.
Gave Rise To 26a. (Signature)' EA Llqa4fi
Murvd bstws•n onset 8 death.
Immediate
Cause OOF 27. IMMEDIATE CAUSE (E TER ONLY ONE CASE PER LINE FOR (a), (b AND (c) t I
t Stating The r _ fJC(~jf.. wl'
PART I (a) /L/
Underlying/~/~L interval astw•n onset 4Ih
i Cause Last DUE TO, OR AS A CONSEQUENCE OF:.. g r... ~ ~ Y. f i t°?I
(b)fANe IlMenal Datwee onaM a deals:.
DUE TO, OR AS A CONSEQUENCE OF:
. (c) WAS CASE REFERRED TO CORONER?
s PART II OTHER SIGNIFICANT CONDITIONS -Conditions contributing to death but not rotated to reuse given in Pan I(a) Y JUI or No (SpecitY' (Specify Yes or No)
26. yes es
ACCIDENT, SUICIDE, HOMICIDE. UNDET. DATE OF INJURY (Mo., Day, Yr.) HOUR OF INJURY DESCRIBE HOW INJURY. OCCURRED..
OR PENDING INVESTIGATION (Specily) aircraft.hit.,ruountain side
3oa. accident 30b. 8"2479 30c. P M 30d. i.
. ~~oOR TOWN STATE s~
INJURY AT WORK (Specify Yes or No) PLACE OF INJURY - Al home, farm, street, factory, office LOCATION: STREET OR R.F D NO. CITY
building, etc. (Specify) at Potphry Peak Lookut,
no 3or. Kings Hill 3~ so. of Neihart
30e.