HomeMy WebLinkAbout956499STATE OF WYOMING 006_ .S
ss.
COUNTY OF LINCOLN
Alice P. Ross of PO Box 716, Thayne, WY 83127, upon her oath deposes and says:
1. That JAMES L. ROSS aka James Larry Ross, the decedent mentioned in the
attached copy of Certificate of Death, is the same person as JAMES L. ROSS named as one of the
grantees in that certain Warranty Deed acknowledged on the 22nd day of September, 1989,
executed by Benjamin E. Skinker, III, and John F. Skinker, single individuals, grantors, and
recorded November 17, 1989, in Book 280 PR, page 260, of the Official Records of Lincoln County,
Wyoming, covering the following described real property located in Lincoln County, Wyoming, to-
wit:
Lot 89 in Star Valley Ranch Plat 12 as platted and recorded in the official records of
Lincoln County, Wyoming.
2. That the undersigned affiant is the same identical person as Alice P. Ross named as
one of the grantees in the above described Warranty Deed, that she and JAMES L. ROSS were
husband and wife at the time of the execution and recording of the Warranty Deed described
above, and that as the surviving cotenant and spouse of JAMES L. ROSS, named in said
conveyance, the undersigned, Alice P. Ross, became on March 7, 2009, the date of the death of
the aforementioned decedent, the owner of the lands or the owner of any interest of JAMES L.
ROSS, in the lands described in the foregoing, subject to any then existing liens and
encumbrances.
DATED the 1st day of November, 2010.
RECEIVED 11/3/2010 at 9:54 AM
RECEIVING 956499
BOOK: 756 PAGE: 616
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
Alice P. Ross
Subscribed and sworn to by Alice P. Ross before me this 1st day of November, 2010.
Witness my hand and official seal.
GERALD L. GOULdIN NOTARY PUBLIC
County of
Lincoln
State of
Wyoming
My Commission Expires May 2, 2011
My commission expires: May 2, 2011.
2
NOTARY PUBLIC
CO 10
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5a A' Bid's iMdaMars)
8a. RESIDENCE -State
0 heahoma 2
8f. RESIDENCE-Street and Number 9437 EQ/S 40th S ee t
t
9. MARITAL STATUS AT TIME OF DEATH
Married:, Never, Married Widowed Divorced
11. FATHER'S NAME (First, Middle Last)
Lee. Ro4.b
13. DECEDENT OF HISPANIC ORIGIN?
(Check the box that best describes whether the
decedent is Spanish/Hispanic/Latino. Check the 'No'
box if the decedent is not Spanish /Hispanic/Latino)
No, not SpanishlHispanrclLatino
❑.Yes, Mexican, Mexican American, Chicano
puert Rid
1 11 1
1 Ba. INFORMANTS NAME
A'Li,ce Rod d
t, Nriddle,.Last, Suffix)
ROSS.
5.14,4;,Wnderl Year
frkii(fis Days
5c. Under 1 Day
Hours Minutes
8b. RESif E CE- County
Tutz a
16. DECEDENTS USUAL OCCUPATION (Indicate type of work done during most of working life) DO NOT USE RETIRED.
Accountant
19 METHOD,.OF DISPOSITION:
R Buria) Cremation E] Donation Entombment
Removal From State Other (specify),
22. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
Stan2eyb Fune'wi SeAvtice
3959 E 31st Sx TuL4a, OK 74135
IF DEATH OCCURRED IN A HOSPITAL:
0900965
A
26, FACILITY NAME (If not institution, give street number
ST F t11' i ialr ihik'
29,, THI, t ytTIM OF,bEATFI
206 lgll it II' I �I ,7
dll.li'I
PI
Sequentially list conditions, if any, b
leading to immediate cause listed
on line a,
Enter UNDERLYING CAUSE
(Disease or injury that initiated
events resulting in death) LAST.
OF INJ.LAY Sete':
c.
STA OKLAHOMA
CERTIFICATE OF DEATH
j Married, but separated Unknown
Yes No Yes In No
Due to (or as a consequence of):
Due to (or as a consequence of):
Due to (or as a consequence of):
City or Town:
6. DATE OF BIRTH
10 /20 /19
2. SEX
M
23. SIGNATURE OF F
Zip Code:
4fi A ll1 a I IF16 i eck �ia ie r l I t Nlili
did i (gym,
A II I p tlpT hl
;TT I❑ p I isidgn iq charge of the patient's care Physician in attendance at time of death only
tl iy �i L b. r k nowle u 1,eath occ97e) at the ime, date a .e and due to the cause(s) and manner as stated.
Mb)CAL EXAMI 'ER: On the basis of examinatiop .r Igation, in my opinion, death occurred at the time, date and
place, and due to the cause(s) and manner stated.
Signature* Certifier:
atSTR�A..R SIGNATURE
2004
3/11/2009
STATE FILE NUMBER'
3 SOCIAL SECURITY NUMBER, "4
7 BIRTHPLACE (City, and State, d'f,1'Fq'ra(ghlCountryY' t',,
Okay Oklahoma
8c. RESIDENCE -City or Town 8 d. RESIDENCE -Zip Code
Rata 74145
14. DECEDENTS RACE (Check one or more races to indicate what the
decedent considered himself or herself to be)
White
��l l ck m
Am or Indian African A or Alaska Native
(Name of entitled or pnnapat tri,fl.�
,Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian (specify)
Pacific Islander (specify)
Other (specify)
10. SURVIVING SPOUSES NAME (If wife give name prior to first marriage)
AtLce Hagen
12 MOTHERS NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)
Etta Ph i.pp
Pi �hestll
y it +ills nl {In� i I I h I W IN I'I"
�Ij�i�41 III�ip� li I Iti il I�IpdP��'..
tltl
Iwl)'i llir
IP i ll I I�,P 1am IIVI I I II'i� I lill���
FYI t :oigradu: =orGE
Some college credit, but no degree
AsSoclate degree�(W1q AA
Bachefot degree/ 1 g,BA A6,a in
Masters 4ree (eg Fd MJ�/ Eng
boctora e, 4YPro}gahIBnal Dd ee
(e g PhD', EdO or MD ,JD, etc)
Accounting
8b. RELATIONSHIP TO DECEDENT 18c MAILING ADDRESS (Street and Number, City, State, Zip Code)
e 1 9431 Ead. 40th St. TuLoa, Ok 74145
20. PLACE OF; DISPOSITION (Name of cemetery, crematory, other place) 21, LOCATION City, Town and State
Fune.'wi Di eetou Cnema ion Snvc TuLaa, OIichama
JI'
24 FH ESTABLISHMENT LICE
25'PLAQ E OF DEATH (Check on v one: see instructions)
IF DEATH OCCURRED OTHER THAN IN A HOSPITAL:
Inpatient Emergency Room /Outpatient U Dead on Arrival ❑Hospice ❑Nursing Home or Long Term Care Facility
27. CITY OR TOWN, STATE AND ZIP CODE OF LOCATION OF DEATH
TULSA, OKLAHOMA 74 3 (f.
i i
31. WAS MEDICAL EXAMINER CONTACTED? 32. WAS AN AUTOPSY PERFORMED?
Iitlh(`k i I I li liiilll I p t cAU$ FOFDEATH (See Instructions and Examples)
34. P ll tho l Ih of e #I ,S diseases injuries, or complications that directly caused the death. DO NOT enter
m
erma 1 p f� is such as cardiac arrest or respiratory arrest, ventricular fibrillation without showing the etiology. DO NOT
ABBREVIATE Enter only one cause on a line. Add additional lines if necessary.
MMEDIATECAUSE (Final disease ATHEROSCLEROTIC CARDIOVASCULAR DISEASE
or condition resulting in death) a.
Apartment Number:
17. KIND OF BUSINESS /INDUSTRY
48. LICENSE NUMBER
21778
ED CT FAMILY EMBER
I
ri r pU�'�IIVI ii r PIP,. iltl I II. II��V
EfA trio I pu,
2 9�i�' h� �li�lid a1P1Vl, IINP, i'f
F �i l "ir',I Idyll P: 1lil I I Ill�l I
u(u� I dIII ry VPII I(�lill 71 'I Ii INS NW'I'
9 tllipl� ei I II Ill 911111 1
idl NI I I I I't 'II I 15 �I
)Decedent's Fto "Other
28. COUNTY OF DEATH
u TULSA /461/0,/s.
33 t WEREAVTOPS'Y FINDINGSiAVA ABLE
TO COM LETE,EY/X SE O )$EAT`
❑lr §S, l141n, l
Approximate
interval:
Onset to death.
Undetermined
36. MANNER OF DEATH 37, IF FEMALE: Ild i V
lu l II
ure
Nat) t� Accident Suicide Not r p nt within past year Pregnant at time of death Not pregnant but prepolfn Within 1' II ,II
I il l i
Pending Investigation ❑Could not be determined Not pregnant, but pregnant 43 days to 1 year before death Unknown if pragpgnt Gi the pas 11 i1 IM 1 b
39. DATE OF INJURY(Mo/DaylYr/I40. TIME OF INJURYI41. PLACE OF INJURI(e.g Decedent' ,e:
stun <onstrecre en
a e, w00 1 42. DESCRIBE HOW INJURY 6CCURRE
Be RESIDENCE- Inside City Limits
,S Yes No
47 NAME, ADDRESS AND;',Z)P C
CAUSE OF:DEATH (Item a4
ANDREW 'SIBLEY M.0
8g. yyS&ENCE- Apartment Number
S ED
35. 1 FART II
r i d hif hranri Atti
contributing to death but
not resulting i n the
underlying cause given in
PART I.
145 IF TRANSPORTATION)N,lURY 9'
OpWg R Plpeeengp
o tn er /r1/ /4
1 49 DATE CERTIFIED
3/8/2009
1
u�ll
ox
I of
it
MBA)
S SUCH
ipQl'I
ill
II I �I
Y AT WORK
Yes No
(Mo/DayfYr)
51. DATE RECEIVEQ BY LOCAL REGISTRAR 52 DATE RECEIVED BY STATE REGISTRAR
MAR 2409 Mo/Da y /Yr I (Mo /Day/Yr)
VS154(1 -04