HomeMy WebLinkAbout956020RECORDING REQUESTED BY
WHEN RECORDED MAIL TO
AND MAIL TAX STATEMENTS TO
Michael Hurley
11 Eccelstone Circle
Irvine, CA 92604
property.
Dated: 10/8/2010
State of California
County of Orange
Signature
AFFIDAVIT OF SURVIVORSHIP
RECEIVED 10/18/2010 at 10:34 AM
RECEIVING 956020
BOOK: 755 PAGE: 451
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, Michael S. Hurley, being first duly sworn on oath, depose and state as follows:
1. I am the surviving spouse and tenant of Gina K. Hurley, who died on the 6th day of May,
2010.
2. The following described real estate was owned only by Michael S. Hurley and Gina K.
Hurley, husband and wife, as tenants by the entireties, at the time of Gina K. Hurley's death:
a. Lot Two (2) of the Ridgecrest Estates Subdivision filed and recorded with the Lincoln
County Clerk on the 10 day of March, 1993.
3. The decedent described in the attached certified copy of Certificate of Death is the same
person as Gina K. Hurley, who is named as one of the parties in the Warranty Deed dated 9 day
of December, 2005, executed by Richard C. Budge and Heather L. Budge to Michael S. Hurley
and Gina K. Hurley, as tenants by the entireties, recorded on December 13, 2005, in Book 607
Page 357 of the Official Records of Lincoln County, Wyoming, covering the abo referenced
1
ss.
Michael S. Hurley
ACKNOWLEDGMENT
Subscribed and sworn to (or affirmed) before me on this 8 day of October, 2010, by Michael S.
Hurley, proved to me on the basis of satisfactory evidence to be the person who appeared before
me.
(A‘MIV1114 (Seal)
DIANE LYNN MANCINELLI
Commission 1835338
Notary Public California
Orange County
Comm. Expires Feb 10. 2013
ERTIFICATIONOF VITAL RECORD
COU N TYHOF ORANGE.
H'EA:LTH::.CA.RE AGENCY
200 :N. MAIN STREET, SUITE:.? 00 -A
SANTA ANA,. CA 92701:
D AT. E.I W ED
ERIC G. HANDLER, M.D.
HEALTH OFFICER
ORANGE COUNT)", CALIFORNIA:
This copy 'not unless prepared ehgrov.2d boGder displaying Seal :and •signature of ,Registrar.,
3201030006213
oi
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STATE
REGISTRAR
STATE FIEF
STATE OF CAL1FQRNIA
COUNTY OF ORANGE
11 :1 NNEI)O[N;I I;
CERTIFICATE OF DEATH
STATE OF CAJF0RIIA
ISE MACK MONO 100. S °R ATEM18HS
LOCAL REGISTRATION NUMBER
1. NAME OF DECEDENT -FIRST (GNe6•
GINA
ANA: ALSO KNOW N AS 08 NI AKA (F
15: EDUCAM1N ,11914411.0.40.944
1..9ew1941 on ImoN
ASSOCIATE_
17. USUAL OCCUPATION- Type of
HOMEMAKER
IRS?, MIDDLE, LAST)
9. BRDN STATE/FOREIGN COUNTRY 110. SOCIAL SECURITY NUMBE
OKLAHOMA.
20. DECEDENTS 4800004 E (50.41 Md nam 00o001
11 ECCELSTONE CIRCLE
21. CRY
IRVINE
26. INFORMANT'S NAME, RELATIONSHIP
MICHAEL HURLEY, HUSBAND
Z5. NAME OF SURVIVING SPOUSF/SROP'{IRST
MICHAEL
31. NAME OF FATHERFARENT-FIRST
JOSEPH,
35. OF MOTHER/PARENT-FIRST
LINDA
39. DATE 0552)90/04
05/07/2010
41. TYPE OF DISPOSMON(S)
CR/RES
44. NAME OF FUNERAL ESTASUSHMENT
THE OMEG'A,SOCIETy
wading l0oa0.. .IC
on Uo. A. Enter
UNDERLYING
CAUSE (41440. or
1999911141 N�
11464149113. 9 2/..104
AIIng In O.dN LAST
01 131 NM, 00 NOT. USE RETIRED'
11 e.I CBROY THAT TO 11/E.9E5T OF M1ti010WLEOGE DAD 0CG1RRE0
AT DHENDU R, DAIS.AIAPIACF G1A1EDFROM THECAUSE55TALED.
Dead. P414.6190nui Dlsadenllw Dan Arne
IA .IA20/0011
10/24/2008
1 mm/44( l7
05/04/2010
22. COUNTY/PROVINCE
ORANGE
125..SIGNATURE OF CORONER/ DEPUTY.CORONER
It EVER .INU.$. ARMED FORGES?
YES Nq D UNK
N weMMmbcq
14/15. WAS DECEDENT NI
YES
CAA
El
NO
19. KIND OF BUSINESS OR W OUSTRY (.F: N 1.6,060.1 0044 11904 pnc8 0187
OWN HOME
29 02100101:'.
SCOTT:`
RUSSELL
06. M100LE
LEA
A6. LICENSE NUMBER
FD1280
20. ZIP CODE
92604
101. PLACE OF DEATH
RESIDENCE :HOSPICE
105. FACSITY ADDRESS OR LDCATIONWHE4E FOUND re number. or 079491
11
119. RFI'
1.CER MATMMY OFNJKXI DEAII=IFFEC THE STATED FROM THE CAUSES Steel
MANNER CF DEATH D:Nsiuial A<24.d Ha4ci1e
49 1
00002
12• DATE
nl
S. LAST (Fa l/)
HURLEY
OATS OFBIR1H 01 V 010 'tCW
10/04/1959
.12: MARITAL STAIUSISRDP' N Tw.404 69
MARRIED
4'1 PLAL ANAL 1SPOSONXI RESIDENCE.OF MICHAEL HURLEY
11 CIRCLE; IRVINE 92604
42.SIONAIURE OFEMBALMER
NOTTEMRALMED:
107. CAUSE OF DEATH END the 191611 o4
CNMa0 anon, .PYNpy0NR.avenk/ wbbr wCU
OonAYw KN
np Me AOSA DO NDTA E'MTE.
IMMEDIATE CAUSE IN OVARIAN CANCER
(FK9H 2 /0.10 0,
00921944 nAARIn4 t
5. AGE Yrs. 't WCW,GG YE-'. ..IFIWOEP j� NIXM15
50 0202/14 D9 ",HNM AwM
19. DECEDENT'S RACE -Up to 0 noes May be K.1ad wWW6.11. on W1 M
WHITE
24. TEND IN COUNTY
7. DATE OF DEATH TIVONA yy.
05/06/2010:.
25: STATE/FOREIGN COUNTRY
I1: CALIFORNIA
2)9117;ECC N 00 CIRCLE, .0d0bm. 0.0.07 E, .CA 4040092604 05 41 00IW00
m .9.2/.12)
nIRVIN
21. LAST (BartiroME1
HURLEY
KENT
57. LAST (BIRTH NAME)
WILCOX
45. SIENx1URE OF. 1:00A,REINSTRAi
ERIC G. HANDLER, M.D.
102: F HOSPITAL. SPECIFY ONE
❑P ❑a-
12/. COUNTY
ORANGE
SENINm.4K9 %«6.135011609- DM LND, mad awls DO NOTANN Ie ninN.mNa sue,
120. INJURED AT WORK?
YES El NO ❑LINK
I11M111111 IIIIII11110pNIIUIpWYI11IIIpIIIN111IIpI111,
'010001001494134'
r KNW1Wynn
0M.10N0000
(An
18 0203
1 2.0 4
SecaedwM• Iwt
oon0I0000. K any.
0)
len
R Tao
115. WAS OPERATION PERFORMED FOR ANY CONDITION N ?TEN 107.011112? (R
715 S10NATUREAN0TITLEOFOERTFEfl
►LISANICQE. M D.
118 TYPO ATTENDING PHYSICIAN'S NAME, MPAING ADDRESS. UR CODE LISA NICOLE A$AID M.D.
351 HOSPITAL RD STE507, NEWPORT BEACH;: CA 92663
FAX AUTH.R
O.SEX
F_
B. HOUR 0 NmNI
0339,
19. YEARS IN OCCUPATION
04. BIRTH STATE
OK
D. BIRTH STATE
OK
43. UCENSE NU
17. 'mMENcyw
05/07/2010
103. IF OTHER THAN HOSPITAL, SPECIFY ONE
000920 008
dnns/LTC Home 145 I�
.106. CRY
'IRVINE
109 DEAD REPORTED 70
I� 070
El
109. OII005Y PERFORMED?
YES
110. AUTOPSY PERFORMED?
0 YES El NO
110, USED NOEIERIDERSCAUSFJ
Q.VES' ,I]
113. OTHER SIGNIFICANT C
NONE
TION5 CONTRIBUTING TO DEATH. BUT NOT RESTATING N THE
RC
CAUSE GIVEN N ?07
I1 T1 FOMLE. FREONANT N LAST YFAA1
I J YES NO O UNK
116. LICENSE NUMBER
A1.04885,
117. DATE no&dN0Cyy
05/07/20;1.0
121. INJURY DATE
122,.mOuRANulourd
com9Naiaj file, 0004.4 ana, 4a.)
123,TXACE OF INJURY 0:9..o
124. DESCRIBE HOW INJURY OCCURRED (0041.
n 10.14440 .94 el
125. LOCATION OF INJURY (SI* and number. orwc011on, and as and 21p)
128. TYPE NAME, TITLE OF CORONER DEPUTY CORONER
.I CENSUS TRACT
This is.a true'and exact reproduction of the document officially
registered and placed on file in:the office of °the VITAL RECORDS
SECTION, ORANGE COUNTY HEALTH
MAY 1: 1 2010
CERTIFIED COPY OF VITAL RECORDS
0. x 52
1 11,1 1 1! 11111111 �NI 11
72943
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<;ALT
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