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AFjIDAVIT OF SURVIVORS IIF
RECEIVED 7/9/2010 at 3'50 PM
E EIVING '95431;4
ss. BOOK 750 PAGE :'!WO
COUNTY OF LINCOLN JEANNE WAGNEIR'
LINCO N: COUNTY C:Lt =kK, KEMMEREP, WY
PEGGY ELAINE McJUNKIN, being ,.first sworn upon her oath, deposes and states
THE STATE OF WYOMING
as follows:
1. On the 11 Day of April, 2003, my husband, James William McJunkin,
passed away, as is evidenced by the official certificate of death attached hereto and
incorporated herein by this reference.
2. At the time of his death my husband owned certain real property with me,
said real property being located in the County of Lincoln, State of Wyoming, and more
particularly described as follows:
Beginning at the Northeast corner of Lot 2 Block 10 in the Afton Townsite,
Afton, Lincoln County, Wyoming and running thence South 10 rods, thence
West 5 Rods, thence North 10 rods, Thence East 5 rods, to the point of
beginning, together with water rights and appurtenances.
Said real property was originally conveyed to James William McJunkin and Peggy Elaine
McJunkin, husband and wife by the entireties, by Warranty Deed dated May 12, 1967,
and recorded in the office of the Lincoln County Clerk and Ex- officio Register of Deeds
on May 15, 1967, in Book 78 PR at page 192.
3. At the time of his death my husband owned certain real property with me,
said real property being located in the County of Lincoln, State of Wyoming, and more
particularly described as follows:
A parcel of land located in Lot 2, Block 10, Afton Townsite, Afton, Lincoln
County, Wyoming (Section 30, T32 N, R 118, W of the 6th P.M., Wyoming).
Beginning at a point which is located 82.5 feet N 87 -30' W of the North Block
Corner (New Survey- 1971) of Block 10 of the original Afton Townsite; Thence 165 Feet
S 2 -37' W; Thence 11.10 feet N 87 -30' W; Thence 165.15 feet N 4 -48' E; Thence 4.15
feet S 87 -30 E to the point of beginning. Containing 0.029 Acres more or less.
Said real property was originally conveyed to James William McJunkin and Peggy Elaine
McJunkin, husband and wife by the entireties, by Warranty Deed dated April 16, 1973,
and recorded in the office of the Lincoln County Clerk and Ex- officio Register of Deeds
on May 7, 1973, in Book 104 PR at page 435.
4. By reason of my husband's death, I am entitled to sole ownership of the
above mentioned property.
DATED this i' zl Day of
STATE OF WYOMING
COUNTY OF LINCOLN
Subscribed and Sworn to before me by PEGGY ELAINE McJUNKIN, this
day of 3 kx 1 2010.
Witness by hand and official Seal.
My commission expires:
ss.
NOTAR
2010.
Pe I Paine McJunkin
PUBLIC
HEATHER WARREN
County of
Lincoln
NOTARY PUBLIC
State of
Wyoming
My Commission Expires December 15, 2010
000301 01
STATE OF UTAH DEPARTMENT OF HEALTH
i, 1 Aqg CERTIFICATE OF DEATH
STATE FILE NUMBER e
LOCAL F ILE NUMBER 10-,,,,,,,
1. NAME OF DECEDENT FIRST MIDDLE LAST 3a. DATE OF DEATH (Mo., Day, Yr.) 3b. TIM 0 E
James William Mr.:JUNK f N Male April 11, 2003 0336
IF UNOER 24 HRS. 6. BIRTHPLACE (City 8 State or Foreign Country) 7. SOCIAL SECURITY NUMBER
I
Cody Wyoming
4. DATE OF BIRTH„:(Mo., Day, Yr.) 5. AGE- Last Birthday IS UNDER YEAR
Sept. .5, 1932 70
51a. -1HOSPITAL puree mays ror tjexpeat eery): I ALL:OTHER LOCATIONS:
Ai:L il y, .0 3. Inpatient 1 5: Pluming Home 6. Residence (any)
2:ER/Outpatierit D. DOA fl 7. Other (spcifY)
CITy, TOWN, OR LOCATiON OF DEATH
1 34... 1 3,ESIDENCE STREET AND NUMBER 13b. CITY, TOWN OR COMMUNITY 13c. COUNTY 13d. STATE
2 40 East 2nd Avenue Aft Lincoln WYamiTlg'
3eri IN4DE OITY 13f. ZIP CODC, 14. WAS DECEDENT or H6PANIC ORIGIN? 15. RACE- Black, White, Am. 16. EDUCATION,(spedly only highest
LIMITS? (ities, SpecIfY) Indian (tribe may be entered), grade,complo(ed) Elementary or
Japanese...MP..(SPeav) EII'mndwi' (.12),Co9ege (13-16
trkkelipan 2. Cuban or 17t)
No 83110 ID 3. Puerto Rican 4, Other (Specify) White 16
7 FATHER'S NAME (First, Middle, Last)
tedriek Lloyd ,Mcjunkirt:
AM ,OHIP AND MAILING D
ADDRESS 0 R
14F9R5LSN E RELATINS
T:". ,FINDRMANT
ggY:,;MC.Innkin, Wile T;:d. Box 336, Afton Wyoming
20. METHOD oF 21,. OF DISPOSITION
3: Other
5. Crematfonn 8. Rernmial Apt'. 11, 2003
22. EIENAT RE OE FPNE SERVICELICENS 23. LICENSEE NUMBER
115349
2 D 9 DEDEASelagIFYI142TPHYSICIAN i-rt,iv, 2003
CERTIFIER
:CERTIFYING OHYSICIAN: To the best of my knowiedge, death occurred at the time, date, and place, and due to the cause(s) and manner as stated.
2. ENFORCEMENT OFFICIAL: On the Pasts of examination and/or investigation, In my opinion, death occurred at the time, dela, place and due to the
,cause(s)and manner as stated.
27b.SIGNA RE /sop TITLE OF -.R
27c LICENSE NUMBER
,Ir)
27d. DATE ILI C3 IGNED (Arfonth, Day, Year)
5124287-1205 0q
28, NAME AND:ADDRESS OF PERSON WHO CERTIFIED THE CAUSE OF DEATH (Item 31) (Type/Print)
eat e orth Medical Drive, Salt Lake •City, Utah 84132
31: ENTER .THE DISEA
OR RESRIRATORY'
mecipvg,clisE (Final
c1116§40coodiff00 reutUng
stai if
anyJaadif,Igtatipmediata,
causEL
CAUS,E4cliae9aapf that,
(9
a
p403 ti.;01flar, Sithilkcefit Conditions contributing to death 32. iN YOU,Ft9PINION, TOBACCO USE BY THE DECEDENT: 33a. WAS AN AUTOPSY 33b.:lryRE AUTOPSY
but nal resulting In the underlying cause given In Pert I PERFORMED? FINDINGS AVAILABLE
1 1. Probably contributed to the cause of death. ID 5. NON USER PRIOR TO COMPLETION
2. Was thelriderlying cause of death. OF CAUSE OF DEATH?
34. MANNEWOR DEATH 35a. DATE OF INJURY (Mo., Day, Yr.) 355. TIME OF INJURY 35d. Fl.p U i.At home, farm, street, factory,
o
Ar)
ilsio..i zAccicierii
35a LOCATION (Street or rure I mute number, city or town, county and state.) 35f. If motor vehicle accident specify if,decedent was driver,
3 I ,tdicIde l-lbrnickle passenger or pedestrian.
ncleietrained S. Pending
Iflejii),:0,4 35g. DESCRIBE HOW INJURY OCCURRED (anMr siquence of events which msulted in injury, NATURE OF INJURY should be entered in item 31)
El 3 Did not contribute to the cause of death.
4 Is unknown in relation to the cause of death
8b. NAME OF HOSPITAL, NURSING HOME OR OTHER FACILITY
(if outside a facility, give street address of location)
UnlyerS,Lty Hospital
8d. COUNT! OF DEATH 9. SURVIVING SPOUSE (if wife, give maiden name)
Sal,t.,Lake Peggy Megeath
11. MARITAL STATUS 13a. DECEDENTS USUAL OCCUPATION (Give' kind of work donp 12b. K910 OF BUSINESS OR INDUSTRY
dufing.most of working (ife. Do NOT enter retired)
LI 1. Never Married Li 3. VVidowed,
2. Married Ei 4. Divorced Wyoming Highway Engineer Wyoming State
DUE TO (ORAS ACONSE5IDENCE OF):.
H .DUE TO (ORLASA ONSECUENCEOF):
26. if not certified by inedical examiner, was death reported to M.E.7
9 yes enter" the date and hour reported.
M.E. CASE NO. 20,031- n n 411
HR. MO DAY
18, MAIDEN NAME OF MOTHER (First, Middle, Last)
Erna.:Mae Horner
21b. PLACE OF.DISPOSITION (name of cemetery,
crematory, or other place)
IPS Crematory
24. FUNERAL HOME (Name and address)
Goff Mortuary, Inc
I.Ves 2. No 8090 So. State St.
Midvale, Utah 84047
30. DATE REGISTRAR NOTIFIED OF DEATH
(Mo., Day, Yr.)
21c. LOCATION City or Town, Stele
Salt Lake City, Utah
30b. DATE FILED (Mo., Day, Yr)
April 11, 2003
El 1. Yes Ei 2. No 1. Yes 11 2. No
i. tNJURIES, COMPLICATIONS THAT CAUSED THE DEATH. DO NOT ENTER THE MODE OF DYING, SUCH AS CARDIAC I Approximate Interval
REST, SHOCK OR HEART FAILURE. LIST ONLY ONE CAUSE ON EACH LINE. I 8 *Veen Closet end
a Eilovx 5-
4 6 6L-t 4-Ai
•DUE TO (OR AS A CONSEOLIENCE OF):
'Uj _IS is S copy of the certificate on file in ,this office. This certified copy is issued
AgctiOti 261-'bf the Utah Code Annotated, 1953 As Amended.
'IL 11, 2003 natumi
TA„iltE Barry E. Nangle
DIRECTOR OF VITAL RECORDS