HomeMy WebLinkAbout9544426011019132HB
RECEIVED 7/19/2010 at 11:30 AM
RECEIVING 954442
STATE OF WYOMING BOOK: 750
PAGE: 646
COUNTY OF LINCOLN SS. JEANNE WAGNER
F.
c LINCOLN COUNTY CLERK, KEMMERER, WY
F.
v
LL c AFFIDAVIT TERMINATING ESTATE
ot
a S I, Lex J. Stones, being of lawful age and first duly sworn according to law, upon my
F oath, depose and state:
a 1. ThatIamofadulta
C a ge, a resident of Fullerton, California, and the
E Affiant herein.
Q
2. That by virtue of the conveyances which are recorded in the office of the
County Clerk for Lincoln County, Wyoming, located at Kemmerer,
Wyoming is recorded a Warranty Deed dated the 21st day of November,
1955, in Book 14PR on page 102 and also a Warranty Deed, dated the
1st day of August, 1958 recorded in Book 29 PR on page 398
both convey unto Franklin W. Stones, Jr. and Audrey M. Stones as joint
tenants and not as tenants in common with full rights of survivorship, the
following described property, to -wit:
See attached Exhibit B.
3. That said Franklin W. Stones, Jr. on the 2. day of
:f4 U .0 f 42005 died and :a copy of the original certificate
of deft, 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 f°A
4. That by reason of death of said Franklin W. Stones, Jr. 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 Audrey M. Stones continuously since the death of the said
decedent.
FURTHER AFFIANT SAYETH NOT.
Dated 7/ 0
State of q
County of 0...4.;re...4 ss.
The foregoing instrument was subscribed and sworn to me by Lex J. Stones
this gi+f day of July, 2010
Witness my hand and official seal.
Svc- 1 \'rrPrck(-
Notary Public
My Commission Expires: S 30 2-o ("j
��i
CALIFORNIA ALL PURPOSE JURAT
State of Califomia
County of Orange SS.
7
Subscribed and sworn to efore me on this flay of
by
KIM THANH GAO
0 COMM. 1863571
NOTARY PUBLIC CALIFORNIA
ORANGE COUNTY 0
+uco COB EXRS SEPT. 2013 b
v v v u M
v v PIE
v v v v v 30, v v
Description of Attached Document
Title or Type of Document:
Document Date/Revision: S■.i t Q l
Total Number of Pages:
Reason for Attachment:
Out of State Document !Pierre Provided
proved to me on the basis of satisfactory
evidence to be the person(s-) who appeared
before me.
Kim Thanh Ban Notary Public
20 10
1.
RECORD
1:
f
39
vt:
11141/14.14:1811
TYPE OR
PRINT in
PERMANENT
HUCK INK
00 NOT USE
FELT TIP PEN
FOR
INSTRUCTIONS
SEE
HANDBOOKS
Ei ct i 0 Married 0 Married. but separated 0 Widowed 0 Divorced til Never married 0 Unknown
11111:=1 L-,,•9 10. EVER 111 U.S. 110. FATI/Eti'S NAME (First. Middle. Last. Suffix) 115. BIRTHPLACE (Slate, Terr(lory, or Foreign Country)
l c e it ARMED
0 2 FORCES? Franklin William Stones, Jr. Wyoming
2 0 y 12a. MOTHERS MAIDEN NAME (First, Middle, Last, Suffix) 12b. BIRTHPLACE (Slate, Tefritory. or Foreign Country)
1
LB I
ICEECIEMI
DISPOSITION
PLACE OF
DEATH
DATE OP
DEATH
CAUSE OF
DEATH
ITEMS 32.38
TAEILLI
FOR EXTERNAL
CAUSES ONLY
(CORONER)
CERTIFIER
IF DEATH W AS
DUE To OTHER
THAN NATURAL
CAUSES,
THE CORONER
MUST
10811010 0040
SIGN THE
CERTIFICATE
PrREGIE1TfOR
ria
0
c
2
DATE FILED BY STATE REGISTRAR:
STATE OF IDAHO
IDAHO DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF HEALTH POLICY AND VITAL STATISTICS
Stale of Idaho
CERTIFICATE OF DEATH STATE FILE NO.
'L Local Reg. 110 4-/ 17
SE% 13. SOCIAL SECURITY NUMBER
1. DECEDENT'S LEGAL NAME (Inc(ude AKA's if any) (First, Midd(e. Last. Suffix)
Franklin William Stones, III
4a. AGE-Las1Birthday 4b. UNDER 1 YEAR 4c. UNDER 1 DAY
Wean 0013 Hours MiruIn
47
-E,
70. RESIDENCE STATE OR FOREIGN COUNTRY 75. COUNTY
4,
Wyoming Lincoln
7d. STREET AND NUMBER
o 131 Griffey Lane, County Road 400
8. MARITAL. STATUS AT TIME OF DEATH
sl No Audrey Meister
13a. INFORMANT'S NAME (Type or Print)
Audrey Stones mother
14. METHOD OF DISPOSITION 15. PLACE OF DISPOSITION (Name and address of cemetery.
R Burial ChCrema(ion crematory. other place) 1
0 Donation 0 Entombment Af ton Cemetery
0 Removal from Idaho
0 Other (Spec' Afton, Wyoming
170, SIGN U 06.-FIERAL SE LIC E R PERSON ACTING AS SUCH
f
29. DID TOBACCO USE
CONTRIBUTE TO DEATH?
0 Yes 0 Probably
0 Unknown
Signature and Title of Certifier
J2..<
30.1F FEMALE (Aged 10.54):
0 Not pregnant within past year
0 Pregnant al lime of death
0 Not pregnant, but pregnant
within 42 days of death
32. DATE OF (10)001' (Mo/Day/Yr) H. TIME OF INJURY
Sp.II month)
DATE OF BIRTH (M0/Day/Y,)
December 22, 1957 Aft:'on, Wyoming
70, CITY OR TOWN
13b. RELATIONSHIP TO DECEDENT
PLACE OF DEATH (3
19a. IF DEATH OCCU RED IN A HOSPITAL: 19b. IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
IN Inpatient oO ER/Outpatien1 30 DOA .0 Hospice facility s0 Nursing home/Long term care facility 90 Decedent's home /0 Other (Specify)
20. FACILITY NAME ((f psi. facility, give street and number) 21. CITY, TOWN, OR LOCATION OF DEATH, AND ZIP CODE 22. COUNTY OF DEATH
Eastern Idaho Regional.
Medical Center
23. DATE OF DEATH (Mo/Day/Yr) (Spell month)
August 12, 2005 August 12, 2005
Idaho Falls 83404 Bonneville
24. TIME OF DEATH 25. DATE PRONOUNCED DEAD (Mo/Day/Yr) (Spell month) 26. TIME PRONOUNCED DEAD
1037 (24ho
27. CAUSE OF DEATH
PART I. Enter the Ico ir_adf,emn1s diseases, injuries, or complications that directly caused the death. DO NOT enler (ermine! events such as card'ac 1 Approximate Interval:
Pest. respiratory arrest, or venlricular fibril lion without showing the etiology. DO NOT AB REVIA Enler only ne cause on a line: I Onset to Death
MMEDIATE CAUSE (Final
V17_, y L.44 4,.... 4.... i d 14,
esulting in death) DUE TD (or as a consequence 09, r
Sequentially list conditions. b. 1.4 tyr I 1 1 )Y„,, 9 r
LAST (disease or injury
sled on line a. Enter Ihe
NDERLYING DAUSE ..,1> i 1 f
i
I any, leading to the cause ouE TO r eS a consequence on:
that initialed the events 6. .._..1A.41
r esulting in death)
000 TO (Or as .r. sequence sly
PART 11. Enter other conditions conlribulino to death but not resulting 10 111, underlying cause given In Pert I
(24hr)
0 Not pregnant, but pregnant 43 days
lo 1 year before death
0 Unknown if pregnant within the past
year
36. LOCATION OF INJURY: Stale Cily/Town or County Zip Code
Slreel and Number or Location Apartment Numbe
37. DESCRIBE HOW INJURY OCCURRED. IF TRANSPORTATION INJURY, STATE THE TYPE(S) OF VEHICLE(S) INVOLVED (Automobile, pickup, motorcycle. ATV, bicycle,
SPECIFYWHICH VEHICLE DECEDENT OCCUPIED, If applicable
TRANSPORTATION j38a. WAS DECEDENT: 0 Driver/Operator 0 Passenger
INJURY ONLY 1 0 Pedestrian 0 Olher )SpeVl
I NC. CERTIFIER (Check only one, based 00 011' 'al COP0 y or vs certificate)
OS PHYSICIAN To the best of my knowledge 0015 urred I the time, do
0 CORONER On the 00615 01 examination d/. nueNtrg Iorr, in my
cause(s) and manner stated.
MM DD YYYY
39d. NAME, ADDRESS, AND ZIP CO CE' FIER (Type 0
Kenneth E. Krell •.3 3200 S. Channi g Way; Idaho Falls, Idaho 83404
4 00. CORONER'S SUBSEQUENT SIGN E IF NECESSARY: The coroner's signal7 in this 'tern supersedes 11101 01 the physician, 40b. DATE SIGNED
and (he coroner becomes (he serge of record.
have reviewed and if necessary amended, the medical section MM DD
4 1a. REGISTRAR'S SIGNATURE 41b. DATE SIGNED
0 Esv, /0 4`025
MM OD MeV
STATI
This is a true and correct reproduction of the document officially registered and placed
on file with the IDAHO BUREAU OF HEALTH POLICY AND VITAL STATISTICS.
0'8 DATE ISSUED: 0.-9.A.-4° 1 (0 \C
4/0
This copy not valid unless prepared on engraved border
displaying state seal and signature of the Registrar.
male j.
CAL INFORMATION
6. BIRTHPLACE (City and State, Territory. or Foreign Country)
Afton'
7e. APT. NO. 71. ZIP CODE 7g. INSIDE CITY
LIMITS?
O PSI No
9. SURVIVING SPOUSE'S NAME (If wife, give maiden name) t
83110
Colorado
13c. MAILING ADDRESS (Skeet and Number. City, S(ate, Zip Code)
P.O. Box 1000; Afton, Wyoming 83110
16. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
Schwab Mortuary
44 East 4th Avenue
Afton, Wyoming 83110
17b. 1 CENSE NUMBER (Of licensee) 18. WAS CORONER CONTACTED?
M 676 0 Yes IR No
34, PLACE OF INJURY (Decedent's horne, farm, Week construction site, 135. INJURY AT WORK7
nUising home, resteurent, forest, etc.)
1 0 Yes 0 No
28a. WAS AN AUTOPSY 2001, WERE AUTOPSY FINDINGS
PERFORMED? AVAILABLE TO COMPLETE
THE CAUSE OF DEATH?
31. MANNER 6 F DEATH
0 Yes 6 Yes O. No
)(No
X ialural 0 HorNcide
0 Accident 0 Pending investigation
CI Suicide 0 Could not be determined
34b. WHAT SAFETY DEVICE(S) DID DECEDENT USE/EMPLOY7
1 0 Seal bell 0 Child safety seat 0 Helmet 0 Alr bag 0 None 0 Unkno
3901, LICENSE NUMBER
place, and due lo the ry,t_al cause(sYmanner slated,
ath occurred at the lime, dale, and place, and due to the
0
JANE S. SMITH
STATE REGISTRAR
1037 (2411r)
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