HomeMy WebLinkAbout956778AFFIDAVIT OF SURVIVORSHIP
RECEIVED 11/17/2010 at 10:07 AM
RECEIVING 956778
BOOK: 757 PAGE: 314
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
STATE OF WYOMING e0a 314
ss.
COUNTY OF LINCOLN
Joan Martin of PO Box 275, Afton, WY 83110, upon her oath deposes and says:
1. That ELMER M. MARTIN, the decedent mentioned in the attached copy of
Certificate of Death, is the same person as ELMER MONROE MARTIN (a /k /a DICK MARTIN)
named as one of the grantees in that certain Warranty Deed dated the 30th day of September,
1982, executed by Kenneth P. Fallon, Jr., and Elizabeth Jean Fallon, husband and wife, grantors,
and recorded October 6, 1982, in Book 192 PR, page 744, of the Official Records of Lincoln
County, Wyoming, covering the following described real property located in Lincoln County,
Wyoming, to -wit:
Beginning at the Southwest Corner of Lot 2, Block 14, in the Town of Afton, County
of Lincoln, State of Wyoming, and running thence North 55 feet; thence East 140
feet; thence South 55 feet; thence West 140 feet to the Point of Beginning together
with all improvements appertaining thereunto.
2. That the undersigned affiant is the same identical person as Joan Martin named as
one of the grantees in the above described Warranty Deed, that she and ELMER M. MARTIN 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 ELMER MONROE MARTIN (a /k /a DICK
MARTIN), named in said conveyance, the undersigned, Joan Martin, became on September 18,
2010, the date of the death of the aforementioned decedent, the owner of the lands or the owner of
any interest of ELMER MONROE MARTIN (a /k /a DICK MARTIN), in the lands described in the
foregoing, subject to any then existing liens and encumbrances.
DATED the /5/11 day of November, 2010.
1
Subscribed and sworn to by Joan Martin before me this /51 day of November, 2010.
Witness my hand and official seal.
GERALD L. GOULDING NOTARY PUBLIC
County of
Lincoln
State of
Wyoming
My Commission Expires May 2, 2011
My commission expires: May 2, 2011.
2
NOTARY PUBLIC
1
CERTIFICATION OF VITAL RECORD
Date Filed
SEPTEMBER 22,
METHOD OF DISPOSITION
REMOVAL FROM STATE
NAME AND ADDRESS OF FUNERAL FACILITY
NALDER'S FUNERAL HOME, SHELLEY, IDAHO
STATE OF IDAHO
DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
This is a true and correct reproduction of the document officially registered and placed
on file with the IDAHO BUREAU OF VITAL RECORDS AND HEALTH STATISTICS.
SEPTEMBER 22, 2010
9 .,.,t,. 1 4 DATE ISSUED. C/ 1�
4 This copy is not valid unless prepared on engraved border JANE S: SMITH
"S. displaying state seal'and,signature of the Registrar. STATE REGISTRAR
O
f
3 ,.6
State File No. 2010
SIX SOCIAL SECURITY NUMBER AGE DATE OF BIRTH
MALE 7d YEARS MAY 24, 1936
BIRTHPLACE PLACE OF RESIDENCE
SACRAMENT CALIFORNIA AFTON, WYOMING
MARITAL STATUS AT TIME OF DEATH NAME OF SURVIVING SPOUSE (II wfe, maiden name) WAS DECEDENT EVER IN
U.S. ARMED' FORCES?
MARRIED JOAN JOHNSON NO
FATHER NAME BIRTHPLACE
RAYMON MONROE MARTIN
CALIFORNIA
MOTHER MAIDEN NAME BIRTHPLACE
MTAIAITI= I=RMA Rannlcc CALIFORNIA
FUNERAL SERVICE LICENSEE
JASON P. MECHAM
DATE OF DEATH TIME OF DEATH CITY,TOWN OR LOCATION OF DEATH COUNTY OF DEATH 1
SEPT. 18, 2010 12:30 P.M. IDAHO FALLS, IDAHO BONNEVILLE
CAUSE OF DEATH (underlying cause tang Approximate Interval Between
Onset and Death e. MYOCARDIAL ,INFARCTION 1 MINUTE
DUE TO (or as a consequence oI):
b ATHEROSCLEROSIS 20 YEARS
DUE'TO (or as a consequence of):
c
DUE TO (or as a, consequence of):
OTHER SIGNIFICANT CONDITIONS' CONTRIBUTING TO DEATH but not resulting In the underlying cause given above WAS AN AUTOPSY
PERFORMED?
CEREBRAL VASCULAR ACCIDENT NO
MANNER OF DEATH NAME OF CERTIFIER TITLE
NATURAL WALLACE ,C. BAKER, M.D. PHYSICIAN
CORONER SUBSEQUENT CERTIFICATION IF NECESSARY
TIME OF INJURY
PLACE OF INJURY
INJURY AT
WORK?
LOCATION WHERE INJURY OCCURRED
DESCRIPTION OF HOW INJURY OCCURRED