HomeMy WebLinkAbout955222I, Francine E. Tedder, being of lawful age and duly sworn according to law, upon
my oath, depose and state:
That under the date of September 3o, 2005, for valuable consideration, Thomas
B. Ryan and Marilyn M. Ryan, husband and wife, by deed of that date, which deed was
duly filed of record in the Office of the Lincoln County Clerk, on October 4, 2005, in
Book 6o0, Page 223, conveyed to Gerald L. Tedder and Francine E. Tedder, as joint
tenants with full rights of survivorship, the following described land, in the County of
Lincoln, State of Wyoming, to -wit:
Lot 616 in Star Valley Ranch RV Park Plat 2, Lincoln County, Wyoming as described on
the official plat thereof
That by reason of said conveyance aforesaid, the said Gerald L. Tedder and
Francine E. Tedder became the owners of said real property, and the title thereto vested
in them continuously from the date of said conveyance, to the date of death of Gerald L.
Tedder, on the 27th day of November, 2008. That by reason of and upon the death of
Gerald L. Tedder, title in the above described real property vested in Francine E. Tedder.
Affiant avers and certifies that Gerald L. Tedder, is the identical party named
with Francine E. Tedder in the aforementioned deed, whose death terminated his
interest, title and estate in said real property; and Affiant attaches hereto, and makes a
part of this affidavit, a copy of the Official Certificate of Death of said decedent, duly
certified by the public authority in which said death certificate is a matter of record.
Dated this .2 3' day of
State of 1 y D
ss.
County of 1—I n c 4
WITNESS my hand and official seal.
SHARON WALULIER NOTARY PUBLIC
COUNTY OF +g STATE OF
LINCOLN t,} WYOMING
Y COMMISSION EXPIRES JUNE 14, 2012
My Commission Expires: -1 a
RECEIVED 8 /30/2010 at 2:43 PM
RECEIVING 955222
BOOK: 752 PAGE: 795
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Affidavit of Survivorship
2010.
OO {''95
Francine E. Tedder
Subscribed and sworn to before me, a notary public in and for said County and
State, by Francine E. Tedder, this 45 day of is g 2010.
r
Notary Public
1
ANY ALTERATION OR ERASURE VOIDS THIS DOCUMENT
ORIGINAL
STATE
COPY
NAME OF
DECEASED
1.
RACE
4A, CAUCASIAN
PLACE OF
DEATH
8. MARICOPA
DATE OF MONTH
BIRTH
7 11 -01 -1944
STATE AND
CITY OF BIRTH
11. SA
USUAL
RESIDENCE
18. ARIZONA
STREET ADDRESS 011 R.F.D.
15E. 1663 W MONTE AVE,
FATHERS NAME A. FIRST
19, RALPH
INFORMANT'S SIGNATURE
21, FRANCINE TEDDER,
BURIAL, CREMATION,
REMOVAL OTHER (Specify)
24. BURIAL
FUNERAL HOME
28. LAKESHO
47c. DUE TO OR AS A CONSEQUENCE OF:
WALDENSTROM'S MACROGLOBULINEMIA
PART 11. Other signiEcant conditions contributing to death but not resulting in the underlying cause given in Pan I
48.
MANNER OF DEATH DAY YR HOUR
NATURA
51.
SUPPLEMENTARY ENTRIES
STATE OF ARIZONA
DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS
CERTIFICATE OF DEATH
DEATH NO.
102 2008 047337
A. FIRST
GERALD
(11 not in USA, name country)
N •RAFAEL, CALIFORNIA
15A. STATE
L DEATH
6A. COUNTY
DAY YEAR
B. MIDDLE
AGE (YEARS
LAST BIRTHDAY)
158, COUNTY
MARICOPA
8. MIDDLE
TAR
DATE
25. 12 -04 -2008
WAS DECEDENT OF HISPANIC ORIGIN:
6B. TOWN OR CRY
MESA
CITIZEN OF WHAT COUNTRY?
INTENTIONALLY LEFT
12.BLAN K
INSIDE CITY LIMITS?
15F, YES
S OF CERTIFIER, PHYSICIAN, MEDICAL EXAM/ R 0
UTLER, M.D. 2525 E CAM
F UNDER 1 YEAR
MOS. DAYS
TEDDER
F UNDER I DAY
HRS. MIN.
8C.
15C. TOWN OR CITY
RELATIONSHIP TO
DECEASED
22 ,SPOUSE
IF YES, INDICATE MEXICAN, SPANISH, PUERTO RICAN,
CUBAN, ETC:
MARRIED, NEVER MARRIED,
WIDOWED, DIVORCED (S
9. MARRIED
SOCIAL SECURITY NO.
15D. ZIP CODE
85202
PREVIOUS STATE
OF RESIDENCE
18 INTENTIONALLY LEFT BLAN
MOTHER'S MAIDEN
NAME
20 GERALDINE
ADDRESS
2,MALE
CEMETERY OR CREMATORY NAME/LOCATION
NATIONAL MEMORIAL CEMETERY OF
26.PHOENIX, ARIZONA
NAME STREET ADDRESS
RE MORTUARY 1815 SOUTH DOBSON RD MESA
CITY AND
TOTHEBEST OF MYHNOWLEDGE, DEATH OCCURRED AT THE TIME, DATE AND PLACE AN
DUE TO THE CAUSE(S) STATED
30 ANO;nE KIRK A. BUTLER, M.D.
DA SIGNED (Mo., Day, Year)
31 ,12-02-2008
HOUR OF ()EAT
NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIF
W ENFORCEMENT AUTHORITY
K RD PHOENIX, AZ 85016
REGI
2
8 E NQQ
43 .026996
RAR'S SIGNATURE
IIELE CASTANEDA MARTINEZ
60. HOSPITAL OR (IF RESIDENCE GIVE STREET ADDRESS)
INSTITUTION
ODYSSEY MESA INPATIENT HOUSE
14A. SUPERVISOR
HOW LONG IN ARIZONA?
1 661 YEARS
AUTHORIZED FOR. CREMATION
da NO
DATE OF. MONTH DAY
DEATH
3. 11 -27 -2008
8. MIDDLE
LICE
STR
NO CRY AND STATE
VE MESA, ARIZONA 85202
EMBALMER'S SIGNATURE
27A. INTENTIONALLY LEFT BLANK
FUNERAL DIRECTOR or person acting as such (SIGNATURE)
JENNIFER LSAMORA,FUNERAL
29A DIRECTOR
ON THE BASIS OF EXAMINATION AND /OR INVESTIGATION, IN MY OPINION DEATH
AT 71 DATU AND PLACE DUE TO THE CAUSE(S) AND MANNER STATED
AT
34. SIGNATURE
AND YFRE
DATE SIGNED (Mo., Day, Year)
PRONOUNCED DEAD (Mo., Day, Year)
37. ON
38
MEDICAL EXAMINER'S SIGNATURE
4i.,
RE INTEN R TIONALLY
45LEFT BLANK
47A. IMMED
CC9 FIN DISEASE OR CONDITION RESULTING IN DEATH) (ENTER ONLY ONE CAUSE ONEACH LINE)
CAR MYOPATHY
47B. DUE TO OR AS "A CONSEQUENCE OF:
AMYLOIDOSIS
DATE OF MO
INJURY
PLACE OF INJURY
SPECIFY
INJURY AT WORK?
WHERE LOCATED?
AUTOPSY
DESCRIBE HOW INJURY OCCURRED
STREET ADDRESS
WAS DECEASED EVER IN U.S.ARMED
EARS OF
COLLEGE
COLLEGE
(1.4 or 5+)
2
ZIP CODE
CERT. NO.
278.
CERT. N0,
29B. F1277
X CCURRED
AD (Hour)
EFT BLANK
APPROXIMATE
INTERVAL
BETWEEN
ONSET
AND
DEATH
XAMINER
STATE
"VERIFICATION BOX" (HOLD BETWEEN THUMB AND FOREFINGER, OR BREATHE ON IT. COLOR WILL CHANGE TO BLUE AND THEN RETURN.)
,yg7lVV r„ 5/6w r
,7Yr'L'k r
CERTIFICATION OF VITAL RECORD
Arizona
Department of
Health Services