HomeMy WebLinkAbout957277STATE OF WYOMING
COUNTY OF LINCOLN
ss
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 August 22,
2006, executed by Deborah L. Zimmerman, a single person to Calvin Q
Lundgren and Karen L Lundgren, husband and wife, recorded as Instrument
Number 921667, on August 24, 2006, in Book 631, Page 400, 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 11 of Block 33 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 of 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
Subscribed and sworn before me by Karen L Lundgren, this 22nd day of
December, 2010.
My Commission Expires f 1
AFFIDAVIT OF SURVIVORSHIP
000153
RECEIVED 12/22/2010 at 1:59 PM
RECEIVING 957277
BOOK: 759 PAGE: 153
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
(30.1M/Ylintt_di'tbrolak-db--)
Notify Public
SAVANNA L, HAWKEli NOTARY PUBLIC
COUNTY OF
LINCOLN
My Commission Expires
STATE OF
WYO ING
Date and. Place of Death:
Additional Decedent Information:
Place of Birth: Nampa, Idaho
Residence Kemmerer, Wyoming
Marital Status: Married Karen Louise Flagg
Armed Forces: No
Name of Father Grant S taker Lundgren
Name of Mother Sylvia Alice Dowdle
Informant:`, Karen Louise Lundgren Relationship:
Disposition:
Method of Disposition." Removal' from State
Place of Disposition: Logan City Cemetery, Logan, UT.
Funeral Home or Facility:
Facility: 1 Ball Family Chapel Evanston, Wyoming
Cause of Death I
The immediate cause is listed on the first line followed by any underlying causes:
(a) Acute Cardiopulmonary Failure
Other Significant
Conditions:
Decedent: State File Number:
\Name: Calvin Quincy. Lundgren
Gender Male Social Security Number
Date Birth: April 09, 1949 Age at the Time of Death:
Date of Death. December 07,2010 County of Beath
City of Death: Kemmerer
Location: South LincolnMedlcal Center PO Box 390'
STATE OF UVYOMING:
DEPARTMENT OF HEALTH
CERTIFICATE OF, D.E.,TH_
Certifier:
Type: Physician
Name: Vincent Hinshaw, DO
Address: PO`Box 390 Kemmerer, Wyoming, 831
Date Filed: December >1.6 2010''
This is a true certification of the document on file in the office of Vital
Stafistics Services Cheyenne Wyoming
DATE ISSUED: Friday December 17
C
This copy ,0 not valid unless.prepared on, paper wrth an. engraved border:
Gladys K. Breeden
Deputy State Registrar
2010- 003874
61 years
Lincoln
/Manner of Death: Natural Death Time of Death:• 18 :30 (Actual)