HomeMy WebLinkAbout953862RECEIVED E at 2:07 PM
RECEIVING 953862
BOOK: 748 PAGE: 586
JEANNE WAGNER Affidavit of Survivorship
LINCOLN COUNTY CLERK, KEMMERER, WY
I, Donna L. Stading, being of lawful age and duly sworn according to law, upon
my oath, depose and state:
That under the date of February 23, 2007, for valuable consideration, Leisure
Valley, Inc., a Nevada Corporation, by deed of that date, which deed was duly filed of
record in the Office of the Lincoln County Clerk, on March 21, 2007, in Book 652, Page
34, conveyed to Edgar C. Stading, Donna L. Stading and Doris V. Fay, as joint tenants,
the following described land, in the County of Lincoln, State of Wyoming, to -wit:
Lot 563 of Star Valley Ranch RV Park Plat 2 Stage 2
That by reason of said conveyance aforesaid, the said Edgar C. Stading, Donna L.
Stading and Doris V. Fay, as joint tenants, became owners of said real property, and the
title thereto vested in them continuously from the date of said conveyance, to the date of
death of Doris V. Fay on the 25th day of February 2010. That by reason of and upon the
death of Doris V. Fay, also known as Doris Virginia Fay, title in the above described real
property vested in Edgar C. Stading and Donna L. Stading, as the surviving joint tenants.
Affiant avers and certifies that Doris V. Fay, also known as Doris Virginia Fay, is
the identical party named with Edgar C. Stading and Donna L. Stading in the
aforementioned deed, whose death terminated her interest, title and estate in said real
property; and Affiant attaches hereto and makes a part of this affidavit, a copy of the
Official Certificate of Death of said decedent, duly certified by the public authority in
which said death certificate is a matter of record.
Dated this day of J 2010.
State of
County of
Subscribed and sworn to before me, a notary public in and for said County and
State, by Donna L. Stading, this Li t IA. day of c JLI D 2010.
WITNESS my hand and official seal.
My Commission Expires: (a 10
dam.
Donna L. Stading
Notary Public
NANCY J. BROWN NOTARY PUBLIC
COUNTY OF STATE OF
LINCOLN WYOMING
MY COMMISSION EXPIRES 10126120
CERTIF OF VITAL RECORD
TYPE, OR
PRINT IN
PERMANENT
BLACK INK
la. DECEASED -NAME (FIRST,MIDDLE,LAST,SUFFIX)
Doris I Virginia FAY
3b. CITY, TOWN, OR LOCATION OF DEATH
Pahrump
5. RACE White
(Specify)
9a. STATE OF BIRTH (If not U.S.A.,
name country) Iowa
13. SOCIAL SECURITY NUMBER
15a. RESIDENCE STATE.
Nevada
18a. INFORMANT- NAME (Type or Print)
Donna Lea STADI G
19a.. BURIAL, 'CREMATION, REMOVAL, OTHER (Specify)
Removal /Burial
20a. FUNERAL DIRECTOR- SIGNATURE (Or Person Acting as Such)
JAMES; LEE
SIGNATURE AUTHENITICATED
TRADE-CALL NAME AND ADDRESS
DUE TO, OR AS F),;,ONSEQUENCE OF
(b) Coronary Artery Disease
1 DUE TO, OR AS A CONSEQUENCE.OF:
(c)
DUE TO, OR AS ACONSEQUENCE -OF:
(d)
PART lI
288: ACC., SUICIDE, HOM., UNDET.
OR` PENDING INVEST. (Specify)
3c. HOSPITAL OR. OTHER INSTITUTION Name(If not either, give'street
and number)
Desert View' Regional Medical Center
9b. CITIZEN OF WHAT COUNTRY
United States
14a. USUAL OCCUPATION (Give Kind of Work Done During Most of
Working Life, Even If.Retired) Sales Clerk
15b. COUNTY
Nye.
6. Hispanic Origin? Specify
No Non- Hispanic
15c. CITY, TOWN OR LOCATION
Pahrump
16. FATHER NAME (First'Middle Last Suffix)
Welter Lee KOHL
18b. MAILING ADDRESS
20b.- FUNERAL
DIRECTOR LICENSE
21a. To the best of my knowledge ,death occurred at the time, date'and place and
m due to the cause(s) stated. (Signature Title) SIGNATURE AUTHENTICATED
ALE
0- 21b. DATE SIGNED (MoIDayNr) 21c. HOUR'OF DEATH
March 03 2010 07:49
m r 21d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
�.._w. (Type'or..Print)
24a. REGISTRAR (Signature).
JENELLE BALDWIN
SiaNATURE At1THENTtCATED
28b. DATE OF INJURY (Mo/DayIYr)
25. IMMEDIATE CAUSE (8NTER ONLY'ONE CAUSEPER LINE FOR (a). (b), AND (c).)
PART I Cardiore 5irator Arrest
i (a)
28c. HOUR OF INJURY
28e. INJURY AT WORK 28f. PLACE OF INJURY- At home, farm, street, factory, office
Yes or No) building, etc. (Specify)
11. MARRIED, NEVER MARRIED, WIDOWED,
DIVORCED (Specify) Widowed
19b. CEMETERY OR CREMATORY N
Desert La
24b. DATE RECEIVED BY REGISTRAR
(Mo /Days r) March 24, 62010
28d. DESCRIBE HOW. INJURY OCCURRED.
3a. COUNTY OF DEATH
Nye
DOA,OP/Emer. Rm. 4. SEX
Outpatient Female
3e.If Hosp. or Inst. indicate DO
Inpatient(Specify)
Emergency Room
7a. AGE -Last,
birthday (Years)
91
7b. UNDER:1 YEAR
MO.S.I DAYS
14b. KIND OF BUSINESS OR INDUSTRY
Hardware
12. SURVIVING 'SPOUSE OR DOMESTIC
PARTNER
15d. STREET AND NUMBER
330 West Inverness Ave
17. MOTHER NAME (First Middle Last Suffix)
Jessie Leona CAT RELL
(Stree or R.F.D. No City or Town, State, Zip)
211 Mohtecito'Pahrullp, Nevada 89048
NAME 19c. LOCATION City or Town State
wn Park Calimesa California 92320
200. NAME AND ADDRESS OF FACILITY
Pahrump Family Mortuary,
5441 S. Vicki Ann; Pahrump NV 89048
22a. On the basis of examination and /or Investigation, in my opinion death occurred at
LI the time, date and place and due o the cause(s) stated. (Signature Title)
E ,,5 22b, DATE SIGNED (Mo /DayNr) 22c. HOUR OF DEATH
22d. PRONOUNCED DEAD (Mo /Day/Yr)
23e. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN; MEDICAL :EXAMINER; OR CORONER) (Type or Print)
Physician ALEX VAISMAN;,D.O. 360,S Lola Lane'Pahrurnp, NV 89048,
8.' DATE OF BIRTH (Mo /DayNr).
January 01, 1919
15e. INSIDE CITY
LIMITS (Specify Yes
orNo) No
22e. PRONOUNCED DEAD AT (Hour)
nt 23b. LICENSE NUMBER
1374
24c. DEATH DUE TO COMMUNICABLE`. DISEASE
'`YES, D NO
Interval between onset and death
Interval between onset and death
Interval between onset and death
Interval between onset and death
27. WAS CASE REFERRED
TO CORONER (Specify Yes
or No) Yes
DECEDENT
IF DEATH
OCCURRED IN
INSTITUTION
SEE HANDBOOK
REGARDING
COMPLETION. OF
RESIDENCE
ITEMS
PARENTS
ISPOSITIO
DE CALL
CERTIFIER
REGISTRAR
CAUSE OF
DEATH
CONDITIONS IF.
ANY WHICH
GAVE RISE TO
IMMEDIATE.
CAUSE
STATING THE
UNDERLYING
CAUSE LAST
DEPARTMENT OF HEALTH AND HUMAN SERVICES 1
DIVISION OF HEALTH �`nC 1 5t4',
VITAL STATISTICS
CERTIFICATE OF DEATH
STATE REGISTRAR
28g. LOCATION
STATE FILE NUMBER
2. DATE OF DEAT.III (Mo /Day/Year)
February 25, 2010.
STREET OR R.F.D. No. CITY OR TOWN STATE
VRS- Rev 20090602
321714-
CERTIFIED COPY OF VITAL RECORDS
This is a true and exact reproduction of the document officially registered and
placed on file in the office of the State Registrar and Vital Records.
NVIN
This c opy is not Valid unless prepared onengrated border displaying date, sear and signature of Registrar.
PBNCO (R6,011/06
is I. I. T- I. i. 1. I, LI .IJA.I.I.I.I.I.I.I.WJ.UJJJJJJJJ
STATE REGISTRAR