HomeMy WebLinkAbout952806STATE OF FLORIDA
COUNTY OF MARTIN
ss.
Arlene L. Ackermann of 4989 SE Hanson Circle, Stuart, FL 34997 -1714, upon her oath
deposes and says:
1. That GEORGE RUSSELL ACKERMANN aka George R. Ackermann, the decedent
mentioned in the attached copy of Florida Certificate of Death, is the same person as GEORGE R.
ACKERMANN named as one of the grantees in that certain Warranty Deed dated the 2nd day of
November, 1983, executed by Leisure Valley, Inc., grantor, and recorded November 18, 1983, in
Book 207 PR, page 573, of the Official Records of Lincoln County, Wyoming, covering the following
described real property located in Lincoln County, Wyoming, to -wit:
Lot 29 in Star Valley Ranch Plat 14 as platted and recorded in the official records of
Lincoln County, Wyoming.
2. That the undersigned affiant is the same identical person as Arlene L. Ackermann
named as one of the grantees in the above described Warranty Deed, that GEORGE RUSSELL
ACKERMANN and she were husband and wife at the time of the execution and recording of the
Warranty Deed described above, and that as the surviving cotenant and spouse of GEORGE
RUSSELL ACKERMANN, named in said conveyance, the undersigned, Arlene L. Ackermann,
became on December 13, 2009, the date of the death of the aforementioned decedent, the owner
of the lands or the owner of any interest of GEORGE RUSSELL ACKERMANN, in the lands
described in the foregoing, subject to any then existing liens and encumbrances.
DATED as of the 16th day of March, 2010.
Subscribed and sworn to by Arlene L. Ackermann before me this ouv day of
2010.
Witness my hand and official seal.
CARMEN Y. NAVY
MY COMMISSION DD760800
�A` EXPIRES: March 15.2012
OFF`'
LROOJ- NOTARY Fl Nom, Discount Assoc. Co
My commission expires: _3//
G 54
2
AFFIDAVIT OF SURVIVORSHIP
(30 1.58
i
am
Arlene L. Ackermann
RECEIVED 4/7/2010 at 9:39 AM
RECEIVING 952806
BOOK: 745 PAGE: 158
JEANNE WAGNER
LINCOLN COUNTY CLE 1MERER, WY
rtiCi�Ii
STAT c ORIDA
`TYPE IN
3 A K I N K LOCAL FILId NO,
1. DECEDENT'S NAME (First, Middle, Lett, Suffix)
GEORGE
9. DATE OF BIRTH: (Month, Day, Year).
MAY 30 1942
SOCIAL SECURITY NUMBER
0. PLACE OF DEATH
:(Check orgy one)
OUNT
ENCEd• il
LORI)!
F DISP,1p
RUSSELL
4e. AGE -Last Birthday
(Years) 67
7. BIRTHPLACE (City and State or Foreign Country)
WHEELING WEST VIRGINIA
HOSPITAL: Inpatient Emergency Room/Outpatient
QN HOSPITAL, Hospice Fgpplty Nursing Homa&ang Term Care Facility
"'w rll glue st(pe Fddress)
��2N IWIRAiL�'INIII�iIMl�ll II 1 II�Pl
14d. STREET ADDRESS
4989 SE 'HANSON „CIRCLE
!p
5e. DECEDENT'S USUAL OCCUPATION (Ind5G14te'lype of work done during most of 4.
D') not doe *Hegredr ENGINEERS
U
OFFICE of VITAL STATISTICS
CERTIFIED COPY
46 UNDER 1 YEAR 40. UNDER 1. DAY
Months Days Hours Minutes
ed ,_Never Married
1 DECEDENT'S RACE (Specify the facet aces f re 4t(he %le: Mor d
o indicate what decedent considered h �IA Y a(��{ Pe {�od be s p�
White
I I I I I
Black or African Amerldan Am /loan Intllarl Native (9 dat tdUe J' II
Asian Indian Chinese Filipino _Japanese 1 1(arean Vl lna'mese Other Aden
Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Isl. (Specify) Othe Specify)
17, DECEDENT OF HISPANIC OR HAITIAN ORIGIN? s X
(Specify If decedent was otWlapa* or Heinen Origin.) Yea 0/ yes, spewly) No Mexican Puerto Rican Cuban Central/SOl{'I
Other Hispanic (Specify)
1 DECEDENTS EDUCATION (Specify the decedent's highest degree orlevel of school completed at time of death,)
Sth or less High school but no diploma High school diplorna or GED X'
College but no degree College degree (Specify): Assoclale Bachelor's _'Master's Doctorate
O. FATHER'S NAME (First, Middle, Last, Suffix) 21. MOTHER'S NAME (First; Middle, Maiden Surname)
GEORGE ANDREW ACKERMANN JOSEPHINE MARY MILLER
(e INF p �NT 6 no ,h IL I II 4 �a I 22b, RELATIONSHIP TO DECEDENT
lu .Ia o., lNy tu i 611 NNil� ll111!(I! x� �11 P!!i Pl�mll WIFE
23&MTREET ADDRESS
iii 4989 SE HANSON CIRCLE
25a. LOCATION -STATE 25b. LOCATION CITY OR TOWN
WEST VIRGINIA' WHEELING
28a. METHOD OF DISPOSITION Burial Entombmen Cremation Doe Ram*
Ram
J2&b. WIF AS
CREMATION, XAMINER. OR BURIAL AT SEA, 270. LICENSE NUMBERI' I!)I �76 St(} It
APPRO GR E AN'Y E D ER7 Yes� �No FO -42634 I I I,. IIIIItI
.2 No �M I PIIINII
26. NAME OP FUNERAL FACILITY I I� I II I I III'
MARTIN' FUNERAL HOME CREMATORY'
296. OR TOWN
961 I II 1�HWAY mIIOIINIIIy(11
29c. STREET A DDR 8$ II I� 6 I I I p. N I I Inu
STUART h I,, III
34994
30. CERTIFIER: A Certifying Physician To the best of my knowledge, death occurred at the lime, date and place, and due to the cause(s) and manner staled, II il�(
(Check one) Medical Examiner On the basin of examination, and/or Invesligallon, in my opinion, death occurred at the time, date and place, due to the oause(s) and rn f( Iatetl 1 I,1'1(1(II"
31a. (Slgtfa� and
a �eri tl ler) 31b. DA SIGNED (mMri/yyyy) 32. TIME OF DEATH (24 hr.) 33, MEDICAL EXAMINER'S CAS b MBE I IIh I IIll( /2- o21z 'IhN�'��'I
�7
i ll'
r °II I
94- •E NUMBER (or Certifier) 34b. CERTIFIER': NAME 35 NAME OF ATTENDING PHYSICIAN (I( other than berg
'2 /2 fV c) ,y, f o -4
36a, CERTIFIER'S STATE 366. CITY OR OWN 380. STREET AtDRES
FLORIDA STUART 1201 SE INDIAN STREET
34997
S y7:ly, -7RAR• Da REG 3TRAR'
A REGISTRAR. /ghat 1 386: DATE FILED BY, y/
l u� �L l °1 �1. 366
DEC 16 2009; r
Deed on Arrivrl
__,Decedent's Home Other (Specify).
I ta. CITY, TOWN, OR LOCATION OF DEATH
STUART
as x No
3. SURVIVING SPOUSE'S NAME (if wife, give Malden ne ne) /I
ARLENE BROWN
4c. CITY, TOWN, OR LOCATION
14e. APT. NO,
late I Other (S Ped!,�Ih4g111111
0 ,F4 a ERVICE Lidgel SEE'O tI(/E RSON ACTING AS SUCH
IIII AA� I I �I�IL,A III III�iIN��
COUNTY OF DEATH
MARTIN
STUART
29a INFORMANT'S MAILING STATE'
FLORIDA
1 23d, ZIP'CODE
3499,,7
5. DATE OF DEATH (Month,
DECEMBER 13
LIT, I
29a ZIP CODE
36d. ZIP CODE
149. INSIDE CITY LIMITS?
Yes k No
FLORIDA DEPARTMENT OF
HEALT
IIIIVhtl0110aIeII .fan, IlaaIWII 111 %11111n ,A,I11II /I/
36468975
THIS DOCUMENT IS PRINTED OR PHOTOCOPIED ON SECUBITY PAPER WITH x WAT'FI`Fa'AARK. OF ;tHE GREAT
SEAL OF THE STATE OF FLORIDA. DO NOT ACCEPT WITHOUT IVERIFYIN THEYRESENOE 0.F THE WATERMARK-
THE DOCUMENT FACE CONTAINS A MULTI-COLORED BACKGAOUND_AND GOLD_EMBUSSED.SEAL THE -BACK.
CONTAINS SPECIAL LINES WITH TEXT AND SEALS IN THERMOCHRO131G INK:
-OH FORM 1947 (08/04)
CERTIFICATION OF VITAL RECORD
pgIA
N
i
i
i
i
i
i