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STATE OF��
Cr SS.
COUNTY OF-JA- ��J� r
I, Ellen Timmreck, being of lawful age and first duly sworn according to law, upon
my oath, depose and state:
1. That I am of adult age, a resident of San Bernardino, California, and the
Affiant herein.
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 17th day of
May t( 1976 in Book 129 PR on page 439
conveys unto A.C. Timmreck and Tom C. Timmreck aka Thomas C.
Timmreck, as Joint Tenants with Rights of Survivorship the following
described property, to -wit:
3. That said A.C. Timmreck on the 2516 day of /1.4,/b/
2 o p T died and a copy of the original certificate of death, 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 "B
4. That by reason of death of said A.C. Timmreck 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 Tom C. Timmreck aka Thomas C. Timmreck continuously
since the death of the said decedent.
FURTHER AFFIANT SAYETH NOT.
Dated 5;/ 2-0/b
State of .f- yt. ti,
)ss.
County of ti 2ria ittLh
The foregoing instrument was subscribed and sworn to me by Ellen
Timmreck this j L)- day of August, 2010
Witness my hand and official seal.
CoMM. 1885312 r
N "'4G-,,;r4
NOTARY PUBLIC- CALIFORNIA ix
SAN BERNAROINO COUNTY
Z MY Cow, ExP. APR. 28, 2014'
My Commission Expires:
AFFIDAVIT TERMINATING ESTATE
Lots 16, 17 and 18 of Block 1 to the Town of Cokeville, Lincoln
County, Wyoming as described on the official plat.
t 4 _,41/u1.&
SAL �201-
Ellen Timmreck
RECEIVED 9/24/2010 at 3:16 PM
RECEIVING 955681
BOOK: 754 PAGE: 283
JEANNE WAGNER
1 Ikln/-s1 I.1 n/t1 If IT/ 0.1 1 1 0 •••r.,rl, .wn.
1:
r1 4.
NAME OF DECEDENT FIRST MIDDLE LAS[
Archie
2. SEX
3e. DATE OF DEATH (Mo., ay. Yr.) 3b. TIME OF DEATH (24 Or, door()
Mav 25, 2004 1730
DATE OF BIRTH (Mo., a Yr.)
Mar. 4, 1911
5. AGE- L. Sbf d 7
93
1 u1 176MI
o� a w. F u
nowr
I
Fobn Canby)
6. BIRTHPLACE (00 5 Sfee w n
Montpelier, Idaho
7 04?CU/: SECURITY NUMBER
Confidential
ee. PLACE 1 100PITAL one wra.pr r ene:I ALL OTHER LOCATIONS:
OF D
(fhsoA ony 1 1. Irlb.ssrd 1 l Nvrip Han. 6 R wld. nu fdry)
0.0 0.0 2 ERJ0•.petNM 03. DOA 1 7. Other (speed')
eb. NAME OF HOSPITAL NURSING HOME OR OTHER FACLITY
(dol48d a ho64 9h.:4b..f.dd...01kntrlw)
Sandy Regional
ion mil se.
mil
DECEDENT
14 ∎g o b�
i 1
13.
0 Q
V
I
CITY, TOWN, OR LOCATION OF DEATH
Sandy
Sd. COUNTY OF DEATH
Salt Lake
9. SURVIVING SPOUSE (Hoak ph. rook). Mow)
none
10..
EVER M THE U.S. 87
ARMED FORCE
1. We �g. No
11. MARITAL. STATUS
e %M
1. Ns* Mari 3. eowed
2. Mewed 4. Divorced
120 DECEDENTS USUAL OCCUPATION Ow kind of work done
during most of ~Nog Ate. Do NOT polio mitred)
Business Owner
0 OF BUSINESS O INDUSTRY
12b. 101 E R
M ns Clothing Apparel
RESIDENCE STREET AND NUMBER
245 E. TJ Drive
130. CITY, TOWN OR COMIMUNTTY
Sandy
136 COUNTY.
Salt Lake
134. STATE
Utah
13.. INSITE7 CITY
50C Y••
2. No
13(. ZIP CODE
84070
14. WAS DEC OF HISPANIC ORIGIN7 1. We 2 No
L7@C
i. mssicsn 2 c•be,
Puerto n 0 4. Ot or (Bpey)
3. PPuerto Rfu d
15. ,dyeRACE BO NK WNW. Mu.
t.11rt (hb 8* (5 b peciq) wywwl
White
IS. EDUCATION (.sp.cMY anryhighest
°r
p�rtltlss e .mpl.O.d/ EYnt�d 'Y *Y (0.12) C60•96 (13-
1 8en
d or
0
8
►AREHTS
17. FATHERS NAME (POW. s,. Loot)
HE Mdd
Carl William Timnreck
19. MAIDEN NAME OF MOTHER (Fk MOM. 9-84
Annie Andersen
INFORMANT
19. NAME. RELATIONSHIP AND MASJNG ADDRESS OF INFORMANT
Robert Tirlmreck (son)\ 245 E. TJ• Drive Sandy, Urah 84070
01300 )10*
1
CETR1FRJl
1f9oLr p
O
20. METHOD OF DISPSm0N
Dollon 3.OIMr
1. Ertfonbment❑ 7 la
at. euBone S. cl.wwknn❑ e. Rwndvel
21e. DATE of IMPOSTOR
J ule 1, 2004
216 PLACE OF DISPOSITION Awn. 9..I.IIVV.
s)
e.•efery. Cr W pens)
rr
Oakeville Cemetery
216 LOCATION Cie a Town. SRN
I
Cokeville, Wyoming
22 810 TOE OF F`' SERVICE LICENSEE
U
0 4LAA VII)'tt vvtl�
23. LICENSEE NUMBER
262018
24. FUNERAL HOME Morro and.ddrwel
Broamhe Funeral Home
a�d
0
W9LS u W0 1YS ICOW se
T11 ryyM.
A BY ('E R71FY
e"
,----21)•••••f.) f
26.1 a Mt owUMfi M er. rd te.d9el eto.nYIN, ao d1.81 1190M4 W M:E7 1. Y« 2ND
er,br dn. lnornr np.He
M.E. CASE NO. x 1 WL MO DAY YEAR
12590 So. 2200 W.
R.iV�on Ut:ah 84065
/j
ER'TIFER
1. CERTIFYING MO PHYSICIAN PHYSICIAN To 6r bW W r7 knowledge d.e6n ommd N the ime. fists, and *or rd fir 1c IM eM+.e(s) end mNnerr u gated gated
F 2.
0 _..,4 FFICNL' On the eels a wnin.9ort smiler YN.Mi9EtiaM1 in my 09 occurred a firth occurred Ms Nn.. dee. pees end dw 1. On
e
i 4L1 r ,.l WIRED L 4i
20. FF E88 OF PERSON WHO WIRED THE CAUSE OF DEATH 31)(7yp.4'rino
Dr Mike. Jensen 50 E. 9000 So. Sandy, Utah
274. LICENSE N(.1NIER
11 1�;: �i
84070
271 DATE.61GNED Month, Coy, reef)
11CO1tTRJlR
29.0E
30s. 30L GATE REGISTRAR NOTIFIED OF DEATH
(Mo., 0.y. W.)
.,May
380. DATE FLED (No., aY, Yr.)
28. 200
�j C
1 -0 J
CAUSS OP
A TM
OJ^
1
UDH -SNIT
Form 12.
Rev. 121911
31. PART: ERMER 114E 14E INAJRIE8. on COMPLICATIONS TINT CAUSED THE MATH. DO NOT ENTER THE MODE OF DYING, *.cm Fs c 190
L'
OR REBPI ATORY SHOCK OR NEMT FAILURE. UST ONLY ONE CAUSE ON EACH LSIE. I
N.MEDIAIE CAUSE Moat S
diatom ar AWN AWN oorx�Slon e. TD (ORAS A UE11�E
in
I/, t" Ili /L ui
If.t fir ,H •'l TO(OR ASA EOUENCE0
Rlfy, m,,,.../l•
UNDERLYING :5.
pp Worm:
A Bonw
it
1
lY that .DUE TO (OR AS CONSEQUENCE OF):
CAUSE Slonsta or Memo events resulting
1n Conebn
PART' IL OOgler 819nIiMn oubb•e15 tdeelh
PA not mulling w TM 9401° given In
32. IN YOUR OPINION, TOBACCO USE BY 714E DECEDENT:
1. Probrlly dnn.buse m 41. dw•se of dwh UMNb1 �5. NON USER
2. Wm Ws MB come d down
IN
El 3. OM not 94*09 to W. cow p1 "Ink "Ink El 6. F 1
0b ORM oMIME
4. Is Y.n In Motion l0 MIME
33e. WAS AN AUTOPSY
PERFORMED?
1. We 42. No
/y
330. WERE AUTOPSY
FINDINGS AVAILABLE
PRIOR TO COMPLEnon
OF CAUSE OF DEATH
1. Yss 2 N
34. MANNER OF DEATH
tg. Neerel 2 Aa0Mae
VV-
03. Suicide 4. Homicide
3. Undierne d 6. Pending
4•�n
8 .s I •M
Riper* or ondr
Aaey
36. DATE OF INJURY (Mo., ay. Yr.)
360. Tf1E OF iegr
(2I IbOTC10UV
INJURY AT ORK7
365. W
0 1. Ye 2 No
3M P OF e k9R•e RPM ebeN. 1
P•�Y1
etcrr too* numb.; dryer loon, marrydror Sties.)
35e. LOCATICN vY
eVry( /ender. was diver.
39. If Q .mMR9W
P...e�n
J
364 0ESCRIBE HOW INJURY OCCURRED Norm onceN wants meth rwdled a Injury: NATURE OF lAUURYWourO h. wlMed in Awn 31)
JUN 1 9 2004
ok85 STATE OF UTAH DEPARTMENT OF HEALTH
W, Ad 18 -2503 CERTIFICATE OF DEATH
LOCAL FI LE NUMBER
DATE ISSUED
SEP 15 2010
This is an exact reproduction of the document registered ih 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 of Vital. Statistics.
Barry E. Nangle
e "444,
State Registrar
1r_vM DILuat
CERTIFICATION OF VITAL RECORD
i
11
111
III 11111 Il
*06 314195*
STATE FILE NUMBER
z00 005b5b
UTAH DEPARTMENT OF HEALTH
Office of Vital Records. Statistics
Salt Lake City, Utah
m
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