HomeMy WebLinkAbout950163AFFIDAVIT OF SURVIVORSHIP
STATE OF WYOMING ) 469
)ss.
COUNTY OF LINCOLN )
Shelly Jensen n/k/a Shelly Lancaster, being first duly sworn on oath deposes and say:
That Shelly Jensen is of adult age and is the surviving wife of Alan Jensen, who
died January 12, 2008, in Smoot, Wyoming, as hereinafter more frilly appears.
2. That by a Warranty Deed dated July 26, 2004, and recorded July 29, 2004, in the
office of the Lincoln County Clerk in and for the County of Lincoln, State of Wyoming, in Book
563 PR, Page 376, Lawrence H. Welch and Lisa A. Welch, husband and wife, conveyed to Alan
Jensen and Shelly Jensen, husband and wife, as tenants by the entireties, of P.O. Box 157, Smoot,
Wyoming 83126, Lincoln County, State of Wyoming, the following described real estate situated
in Lincoln County, State of Wyoming, to-wit:
That property as described on Exhibit "A", a copy of which is attached hereto
marked as Exhibit "A" and by this reference made a part hereof.
SUBJECT TO reservations and restrictions contained in the United States Patent
and to easements and rights-of-way of record or in use.
TOGETHER WITH all improvements and appurtenances thereon.
That Alan Jensen died on the 12 day of January, 2008, in Lincoln County, State
of Wyoming, and thereupon, the certificate of his death was duly filed with the State of Wyoming
and made a matter of record in said office, and a certified copy of said certificate is attached hereto
and made a part of this affidavit.
6. That upon the death of Alan Jensen, as aforesaid, the joint tenancy created by the
aforesaid deeds were terminated, and Shelly Jensen, surviving wife, became vested with all of his
right, title and estate in the above property.
DATED this a day of October, 2009.
RECEIVED 1012312009 at 10:22 AM
k / RECEIVING # 950163
BOOK: 734 PAGE: 469
Shelly Jens n/k/a Shelly Lancaster JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
SUBSCRIBED AND SWORN to before me by Shelly Jensen n/k/a Shelly Lancaster this
day of October, 2009.
Oerlk
BECKY BARBER NOTARY PUBLIC ~~I\
state of Notary Publ
County of a
Lincoln Wyoming
My Commission Expires August 31, 2010
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.LOCAL FILE NUMBER._ (r4K1lt14ArC VP YGNi fi
:1. DECEDENT'S LEGALNAME (mdads AIUI@ d..Y) (PrO, M14% LMU 2 .SEX 3 DAT6:OF DEATH IL1orD.rTYrI M R4,)
Male Janua 12, 2008 l
Alan R Jensen rya, SOCIAL SECURITY NUMBER 3 rim) LwtBMJx%Y Sb. UNDER 1 YEAR Sc. 1 DAY e: DATE OF BIRTH (MdD.YFYr)
55 Ma tlR o,Ya Heuo, ..:"mw..::. July 14, 1952
ts: FtiACE oK DEATH (I,y1«EIXaY.are) , NCplM~i p Od Crook
IF DEATH OCCURRED INAf1OSP1TA1:: IF DEATH OCGURRED30MENINERE UTHFR tww A HDSPITA4. ,y
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7b. FACILITY NAME (Ifnot naWAW, WIRAMI d Mmbef) 1, CITY, TGNN; OR LOCATION OF DEATH 7d. COUNTY OF DEATH
m
Brill pTeton National Forest; East ofsmoot East of Smoot Lincoln
'..Q :S. BIRTHPLACE (GNW aYY IX,(aleltla aaxrNl9 B. MAFITAL STATUS AT IIM EOF DEATH,., t1. SURVIVIrY6;3PGU8E (IfYJb, W*aaMa PdIXbTYRT.rMPa)
[~(Ml,Ied til Manbd bM aeaemea (7 Ydar»d Shdi Welch ,
m w >SaltLeke'City, Utah ❑UMOrud ONeY«iAanbd OuaaoM Y
1L: RESIDENCE-STATE iJb. COUNTY 12a. CITY, TONM OR LOCATION
1,EVERIN U.S.
ARMED FORCES? -Smoot
J: AYES i~NO Wyoming 'Uncoln
p, Q r _ 15e. LP CODE 12f. WSIDE CITY LIMITS?
12d:STREETANO NUMBER
p f .'83126 'EVES ~NO
353 Smoot Forest County Rd* 152
m.LL f3 . FATHERS NAME (FYM . MM*, L- f1.MOTNER'SNAMEP M7fIFIR3T MARRIAGE (FYd; wiles, use
IS Marvin Don Jesnen Leone Richardson .
INFORMANT S "AMe 1$b ItEJAnONSwProGECeoENr iia.MMUN[i ADDRESS (Sn'VN.M Tlfmlber Dlry 6bY. 2IP Codb)
I
Shelly; Jansen Wife 353 Sm tsok<RorOW County Rd. # 152 ,Smoot, Wyoming 83126
iS.MAEYTHOO OF DISPOSITION +7.. PLACE OF DISPOSITION"" of 17b. LOCATION- CITY OR TOWN AND STATE
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426 Schwab Mortu
n 22. TIME
A. ACT PRE PRONOUNCED 23. VMS CORONER CONTACTED?
TIME OF DEATH 21..DATE PRONOUNCED OF?D (MdMy r).
13:45 Approximate January 12, 2008 14:04 ~fYE3 oNG
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. DATE OF INJUR\"(MWDrylYr1' 31 TIMEOFIrIJURY : 32. LAC E-OFINJURY (DeenNnn llame,'wM+raY?R
Q1112/2008 13 3pppprox Nom Fork of Cottonwood Creek IVES DA NG
. 38AF.TRANSPOWATION ACCIDENTS 6PEGKY:...
K.LOCATION OF INJl1RY lsraatend mlmtM CxY TowA, SYIe)...:.. 11Gar.rf OP.R- ❑Ped.erbn
Bridger Teton National Forest, Wyoming , 0P.a•-1PN 00UM )
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