HomeMy WebLinkAbout957276STATE OF WYOMING
ss.
COUNTY OF LINCOLN
I, Karen L Lundgren, being of legal age and first duly sworn, deposes and says
as follows:
1. That Calvin Q Lundgren, the decedent mentioned in the attached certified
copy of the certificate of death, is the same person as Calvin Q Lundgren
named as one of the parties in that certain Warranty Deed dated July 8, 2004,
executed by Daniel M. Short and Iris M. Short, husband and wife to Calvin Q
Lundgren and Karen L Lundgren, husband and wife, recorded as Instrument
Number 901320, on July 23, 2004, in Book 562, Page 784, of the Official
Records of Lincoln County, State of Wyoming, concerning the real property
situated in the County of Lincoln, State of Wyoming and described as follows:
Lot 9 of Block 39 of the First Addition to the Town of Kemmerer, Lincoln
County, Wyoming as described on the official plat thereof, together with all
buildings, improvements and appurtenances thereon situate or in anywise
appertaining thereto
2. That I am the same Karen L Lundgren mentioned in the above referenced
Deeds and thereby am a person interested in the effective property or the title
thereto and pursuant to 2 -9 -102 W.S. (1980) hereby make the death a
matter of record and certify that upon the death of Calvin Q Lundgren, his
previous estate in the property was terminated.
3. That the certified copy of the certificate of death indicates that Calvin Q
Lundgren died on December 7, 2010 in the City of Kemmerer, County of
Lincoln, State of Wyoming.
Dated this 22nd day of December, 2010.
STATE OF WYOMING
ss.
COUNTY OF LINCOLN
AFFIDAVIT OF SURVIVORSHIP
040151
RECEIVED 12/22/2010 at 1:58 PM
RECEIVING 957276
BOOK: 759 PAGE: 151
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Subscribed and sworn before me by Karen L Lundgren, this 22nd day of
December, 2010.
My Commission Expires 1/27// i
Notify Public
SAVANNA L. HAWKES NOTARY PUBLIC
COUNTY OF
LINCOLN
STATE OF
WYOMING
misionExpires t
Other Significant
Conditions:
'Manner of Death:
riflYWO
Calvin Quincy Lundgren
mate
April 09, 1949
Date and Place of Death
Date of Death: December 07, 2010
City of Death: Kemmerer
I..ocation: South Lincoln Medical Center po Box 390
Additional Decedent InfOrmation:
Place of Birth: Nampa, Idaho
Residence: Kemmerer,
Wyoming
Marital Status: Married Karen Louis
Armed Forces: No
Name of Father: GratitStaker Lundgren
Name of Mother: Sylvia Alice Dowdle
Informant:\ Karen Louise Lundgren Relationship: Wife
Disposition:
method of Dispositions: Pernoval from State
Place of Disposition: Logan City Cemetery, Logan, UT.
Funeral Home or FaCility:
Facility: Bali Family Chapel, Evanston, Wyoming
Cause of Death:
The immediate cause is listed on the first line followed by any underlying causes. I nterval
(a) Acute Cardiopulmonary
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne,
This eopyja not yalid unlese.prepared oa.paper with arkengrayed,horder,:
State File NUMber:.
SocaI Security
Age at the Time of Death:
Certifier:
Type: Physician
Name: Vincent Hinshaw, DO
Address: PO Box 390, Kemmerer Wyoming, 83101.
Date Filed: December16, 2010 sis
Time ofDeatts, :1.8:3O (A
Gladys K. Breeden
Deputy State Registrar
At%':d
CERTIFICATI ITAk. RECORD: