HomeMy WebLinkAbout954000STATE OF WYOMING
COUNTY OF LINCOLN
Dated 5 /1— /G/
State of O,
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County of /NJT
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AFFIDAVIT TERMINATING ESTATE
I, Michael R. Calvert, being of lawful age and
upon my oath, depose and state:
1. That I am of adult age, a resident of
herein.
FURTHER AFFIANT SAYETH NOT.
Witness my hand and official seal.
My Commission Expires:
RECEIVED 6/16/201u at 1 1.35 AM
RECEIVING 954000
BOOK: 749 PAGE: 222
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
first duly sworn according to law,
Hillsboro, Oregon, and the Affiant
2. That by virtue of the conveyance which is recorded in the office of the
County Clerk for Lincoln County, Wyoming, located at Kemmerer,
Wyoming in Book 254PR on page 90 is recorded a Warranty Deed. The
Warranty Deed, dated the 18th day of August, 1987 conveys unto Ralph
Calvert, Beatrice Calvert, Terry B. Calvert, and Michael R. Calvert as
joint tenants with full rights of survivorship, the following described
property, to -wit:
Lots 7, 8 and 9, Block 12 of the Town of Diamondville, Lincoln
County, Wyoming as described on the official plat thereof.
3. That said Beatrice Calvert on the 21st day of January, 2009, died and a
copy of the original certificate of death, certified to as 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 Beatrice Calvert by reason of 2 -9 -102
W.S. (1980), the decedents interest and title in said conveyance has
terminated and title to the real property conveyed thereby has vested
absolutely in Terry B. Calvert and Michael R. Calvert continuously
since the death of the said decedent.
The foregoing instrument was subscribed and sworn to me by Michael R.
Calvert this 7 day of May, 2010
5JkLU
Notary Public
OFFICIAL SEAL
SHERI L ANDERSON
NOTARY PUBLIC OREGON
COMMISSION NO. 414472
MY COMMISSION EXPIRES FEB. 21, 2011
1. LEGAL NAME.OF DECEASED (Include AKA's, any) (Fk t Middle, Last) l (Maiden) 2
2. DATE OF DEATH ACTUAL OR PRESUMED
01/21/2009'
3, SEX 4
4. DATE .OF BIRTH 5
5, AGE -Last Birthday I
IF I INDFR 1
1 YR I
IF LINDFR 1 DAY 6
6. BIRTHPLACE (City State or Foreign Country)
Mo_ D
Days. H
Hours M
Min/
7. SOCIAL SECURITY NUMBER 8
8. MARITAL STATUS AT TIME OF DEATH U Married 9
9 SURVIVING SPOUSES NAME (If wife, give name prior to first marriage)
10e. RESIDENCE STREET ADDRESS 1
10b. APT, NO. 1
10c. CITY OR TOWN
10d. COUNTY 1
10e. STATE 1
10f. ZIP CODE 1
10g. INSIDE CITY LIMITS?
11. FATHERS NAME 1
12. MOTHER'S NAME PRIOR TO FIRST MARRIAGE
1 3. :PLACE OF DEATH (CHECK ONLY ONE)
IF DEATHIOCCURRED IN A HOSPITAL: F
F DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
14. COUNTY OF DEATH 1
15. CITY/TOWN, ZIP (IF OUTSIDE CITY LIMITS. GIVE PRECINCT NO) 1
16, FACILITY NAME (If not institution, give street address)
17. INFORMANTS NAME RELATIONSHIP TO DECEASED 1
18 MAILINGADDRESS'.OF INFORMANT\Street and Number,City,Stete,Zip Code)
19. METHOD OF DISPOSITION. 2
20. SIGNATURE AND LICENSE NUMBER OF FUNERAL DIRECTOR'OR PERSON
21
Block
Lot
22. PLACE OF DISPOSITION (Name of cemetery, crematory, other *CO 2
23. LOCATION (City/Town, end State) L
Space
24, NAME OF FUNERAL. FACILITY 2
25. COMPLETE ADDRESS OF FUNERAL FACILITY (Street and Number, City, State, Zip Code)
28. CERTIFIER (Check only one)
Certifying phyilden -Td Me beet of my lwowlsd9e; death occurred do. to Pm uuae(a) and miner acted.
El Medical Examiner /Justice of 1hc,Peao. On Um beets of examination, end /or Investigation, In my opinion. death occurred at Ihe time,date and place, and due to the cause(.) and manner stated.
27.SIGNATURE OF CERTIFIER 2
28. DATE CERTIFIED (Mo/Dey/Vr) 2
29. LICENSE NUMBER 3
30. TIME OF DEATH(Actusl qr presumed)
ber, Cily Slele;Zlp Code) 3
32. TITLE OF CERTIFIER
l i
33. PART 1. ENTER THE CHAIN OF EVENTS DISEASES, INJURIES, OR COMPLICATIONS -THAT DIRECTLY CAUSED THE DEATH. DO NOT ENTER A
Approximate interval
TERMINAL EVENTS SUCH AS CARDIAC ARREST, RESPIRATORY ARREST, OR VENTRICULAR FIBRILLATION WITHOUT SHOWING THE O
I Dite to (on es seoessiquende of):
Sequentially list conditions/
UNDERLYING CAUSE Due to (or as a consequence of)
CERTIFICATION OF VITAL RECORD
GERALDINE R. HARRIS
STATE REGISTRAR
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P TE OF
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DEPARTMENT OF STATE 'HEALTH
„SERVICES
VI UNIT
AFn §l 6S p,RTMENT OF STATE HEALTH SERVICES VITAL STATISTICS
TA uu TEXAS CERTIFICATE OF DEATH
C223
STATE FILE NUMBER 142 -09- 003846
EDR Nyep�BER '000 05178
i nits Is a t rue a nd corre reproduction of the original record as recorded in this office. Issued under
autho jty of Section 19a,0511 Health and Safety Code.
ISSUED
JAN 28 2009
ARU