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Hickman
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SINCE 1904
1
AFFIDAVIT
C Gi132
I, THERESA W. JERMSTAD, being first duly sworn on oath, depose and say:
That I am a citizen of the United States of America over the age of 21 years, and a
resident of WYOMING.
That I was well and personally acquainted with GLEN LYNCH JERMSTAD.
That I know of my own knowledge that GLEN LYNCH JERMSTAD mentioned in the
attached Certified Copy of Certificate of Death was one and the same person.
This affidavit is intended to terminate the Trusteeship of said in said Trust in the
following described property:
LEGAL DESCRIPTION
Tax Roll No. 37182941703400
Dated this 10TH day of June 2010 A.D.
THERESA W. JERMSTAD
RECEIVED 7/2/2010 at 3:43 PM
RECEIVING 954233
BOOK: 750 PAGE: 132
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
63026
STATE OF WYOMING
SS
County of TETON
On the 10 day of June A.D. 2010 personally appeared before me THERESA W. JERMSTAD
the signer(s) of the within instrument, who duly acknowledged to me that he /she /they executed
the same.
Commission expires: 5/19/2012
Residing in: TETON COUNTY
INDIVIDUAL ACKNOWLEDGMENT
EUSSA 6APENER N: AR U= C
County of State of
Teton Wyoming
My Commission Expires Ma 19, 2012
Notary Public
MELISSA CAPENER
00A.33
s, CERTIFICATION OF VITAL RECORD
'.3 4 1 Ki: `RS k 67 :�1:
%iii
.p(�rgA x1y =E
LOCAL FILE NUMBER
1. DECEDENTS LEGAL NAME (includeAKA'V d
Glen Lynch Jermstad
4 SOCIAL SECURITY NU
PLACE 170. DEATH
IF DEATH OCCURRED IN AHOSP1 TAl
inpatient IAER 71Hdpc09M DOA
76. FACILITY NAME
St. Johns Hospital
6 BIRTHPLACE (City end Nate or foreign country)
Pensacola; Florida
11. EVER 44 US
ARMED FORCES?
OYES CXNO
12d. STREET AND NUMBER
790 Lodge Ln
13. FATHER'S NAME (Fast. mime, Lest)
Glen Lynch Jermstad
5e. AGE- '100( 1201day
(Vitiate)
49'
50. UNDER 7 YEAR
B. ,MAR(TA DEA184
,i�Aletliea Qwnie&tnt, op.m d Ow ,lgw
Oav«an O'NaaaMliiJiee''' Ot1nr6iaaw,
Cramatnry
18th NAME OF FACILITY
alley MOPtua
16. METHOD OF DISPO&51ON
171 Bawl O Doneba, O RemclaLfrom WyaMig
1Ztcrama0n O Entombment 0 Ogler
180. SIGNATURE UNE SERVICE LI SEE 13b LICENSE NO
Pere..
20
20. ACTUAL OR PRESUMED PINE OF Dr�Y,
14:58
'21 DATED .RCNO.UN CEF1,tlEAD (lbw
Dey5Y1)
January, 04, 2008
CAUSE OF FATH
24 PARTI Enter the chin o f eva dioee0 Or OOa th0[ C A a .00 NO
::.eneM. respaeary.elrw). orve43yiWbr 6bNbtlonw .ha4slto gy. 00 NO T M9REViA TE Ereronyo,0 uueenna W,a 03 440apalu4M»a
a neceeeery. 1
IMMEDIATE CAUSE(Fial dineseaa yY\ p ti S�I
ondmon rewNnp.m tlWlh) DUE'r0( ac 4PSr�8060#0e
sagaenmthi ldi ,meonc H y
waagn the name YINGGA the b �nT l
ON UNDERLYING Injury CAUSE
events in M a initialed initialed Si.
d the DUE TO (or Nea Q?mOR OB:
eve. M,g'n Math) LAST.
t /5 DUEtO(ara
r .4c(2t5I sttq 2 *e.4. 514 n
PART H. Enter o04 aignif nt condd
contributing to
IXYES ONO':
26. WERE AUTOPSY FINDINGSAVAILABLETO COMPLETE THE CAUSE OP DEATH
26. IF FEMALE AGED 50.64
.0 Not pregnant whin poet year
Prapnanl ae, bme of death
d Not pregn.r1; 803 pregnant within 42 deg. of
ONot preglan ad pregnant43deyeld1
Unknown dpr.yMO( ple pawyoie
30. DATE OF INJURY (MD/Day/Yr)
34. LOCATION OF INJURY (Street and number. City or T ,orr. Sate)
376. DATE C
3. DATE OF DEATH (MolDayfrr) (Spee Month)
January 04, 2008
6.:pATE: BIRTH (MOEMWTr)
April 15,1958'
IF DEATH OCCURREO SOMEWHERE' OTHER THAN A HO6PRAL::
O Noap,ceFaoNty Nonei. Lang termcan, Fec0y 00.404843. Horde
7c. CITY, TOWN, OR LOOS,TSON OF: DEATH
Jackson
ta.. YW CODE
.83128
wma,won NM, Lamb ex:)
38a. REGISTRAR'S SIGNATURE
10. SURVMNGSPOUSE RN*. -Nth name pnv to mamas.)
.Theresa W. Krumdick
LOCATION
14. MOTHER'S NAME FR10R70 FIRST Mat
Merle 'Kattert'ohn
17b ;l:OCATION.. CRYOR TOMMAND':STATE
Jarlcsnn_WY
112. ADDRESS OF FACILITY
Box 9059. Jackson, Wvpmina
D
W CITES CORONER CONTACTED?
AYES ONO
25. WASANAUIOX6Y.:.-
PERFORMED?
C(YES ONO
27 DID TOBACCO USE CONTRIBUTE TO DEATH?
LSO YES in NO ❑PROBABLY
35. IF TRANSPORT AT10NACC�EIR; SPECFY
ODnwt10pe1Mor "Opateabfae..
OPe:eage OO6er( 3)
36. DESCRIBE HOW INJURY OCCURRED. AND IF TRANSPORTATION INJURY,: THE TYPE(S)
Signature or Crab
a0(.) erg manner Meted.
date ald Pla;., ald. due to
37e. CERTIFIER (Check only are)
n PHYSICIAN- Tone boat of myitrnwloge. death wooled at toe tune. data and piece:,: and doe
CORONER On the Oasi aMnaton, anNarcastlgabon sal. meth aFered state
71C NAME, TITLE AND ADDRESS OF CERTIFIER (Type Gluing
Robert L. Campbell, Coroner
PO Box 2099 Jackson, WY 83001
This is a true certification of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming,
DATE ISSUED: FEB 2 2 20
This copy is not valid unless prepared on paper with an engraved border.:...
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
STATIS11CAL INFORMATION
Gladys K. Breeden
Deputy State Registrar
EXHIBIT "A"
c, &A135
Loan No.: 2961005088
Lot 209, Lake View Estates Incorporated Tract (A) a subdivision of the South half of the Southeast
Quarter of Section 29, T37N, R118W of the 6th P.M., Lincoln County, Wyoming.
(DoD) RA0275183 exhibitA.ra 01/19/2009