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SINCE 1904
AFFIDAVIT
000263
I, Ke,u i v.. A-_ T n e 5 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 l y r�w, v4-1 -ek t�
That I was well and personally acquainted with 6raysovt t4 T vtes
in that certain Warranty Deed dated 13 =3'u 20ob and recorded
in Book Lty at Page 5 7 `I as Filing No. .96 cY? in the
office of the Recorder of 2; vi c c(14 a u K 7Y County, Utah. t,V Y, t�
That I know of my own knowledge that in the said deed and mentioned in the attached
Certified Copy of Certificate of Death was one and the same person.
This affidavit is intended to terminate the eK`Fs 6y- it&iiri of said
in the following described property: he. oltew,iny +cctc o`f (avid vt 'L .ojvt Co ,u ty owe t
TGt� s c u'I'h Fke t- o4 +he- vNvv'44 kaIC (s V, N %z') 4 4- ket b o� Y f!
Sc: v,wvIcio 5" No Ianye, 112 west, o1 fe.t4 Pr i., Wycs,tivt,
Tax Roll No.
Dated this 24 day of
2 /D
2A.D.
K -e..0114/1 0 ?-Yue.0
RECEIVED 7/8/2010 at 12:07 PM
RECEIVING 954288
BOOK: 750 PAGE: 263
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
STATE OF UTAH
County of
On the 0 2 C day of
Commission expires:
Residing in:
INDIVIDUAL ACKNOWLEDGMENT
j
the signer(s) of the within instrument, who duly acknowledged to me that he /she /they executed
the same.
,c /b
A.D. 2613P personally appeared before me
Notary Pubii
LINDA N. JENNINGS
Commission 0577116 1
My Commission Expires
January 9, 2013 I
State at Utah
y Public
0:400264
CERTIFICATION OF VITAL RECORD
DECEDENT INFORMATION
Date of Death: May 27, 2007
City of Death: Logan
Age: 85
Place of Birth: Tabiona, Utah
Armed Services: Yes
Spouse's Name: Loma Hansen
Industry/Business: Sheep
Residence: Hyrum, Utah
Mother's Name: Mary Grayson
Facility or Address: Logan Regional Hospital
INFORMANT INFORMATION
Name: Loma H Jones
Mailing Address: 262 West 300 North, Hyrum,
DISPOSITION INFORMATION
Method of Disposition: Burial 'i
Place of Disposition: Hyrum City Cemetery, Hyrum, Utah
Date Issued: May 31, 2007!
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CAUSE OF DEATH
Ventricular Fibrilation
Probable Coronary Artery Disease [Onset: 1 Hour]
Acute MI [Onset: 1 Hour]
Tobacco Use: Non -user
Medical Examiner Contacted: No Autopsy Performed: No
Barry E. Nangle, State Registrar
Office of Vital, Statistics
CERTIFICATE OF DEATH
State File Number: 2007006032
Time of Death:
County of Death:
Date of Birth:
Sex:
Marital Status:
Usual Occupation:
Education:
Father's Name:
Facility Type:
Relationship:
Utah 84319
FUNERAL HOME INFORMATION
Funeral Home: Nelson Funeral Home
Address: 162 East 400 North, Logan, Utah 84321.
Funeral Director: Michael Chatterton
MEDICAL CERTIFICATION
Certifying Physician: Brett Porter, 550 East 1400 North, Logan, Utah 84341
Manner of Death: Natural
18:21
Cache
April 15, 1922
Male
Married
Rancher
Some College but No Degree
Harold Guy Jones
Hospital ER
f'
Date of Disposition: June 1, 2007
Lloyd Berentzen
Director /Health Officer
County/District Health Department
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This is an exact reproduction of the document registeted in the State Office of Vital Statistics.
Security features of this official document include: Intaglio Border, V R images in top cycloids,
ultra violet fibers and hologram image of the Utah State Seal, over the words "State of Utah This
document displays the date, seal and signature of the State Registrar and the County /District Health Officer.