HomeMy WebLinkAbout957370STATE OF WYOMING
)ss.
COUNTY QF LINCOLN
RE(° ED 12/28/2010 at 12:00 PM
KtUEIVING 957370
BOOK: 759 PAGE: 446
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
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g on oath deposes and states:
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1. That by Warranty Deed dated the 1 day of September, 2005, BARRMORE, LLC
conveyed to Brad Morehouse and Leslie Morehouse certain real estate more particularly
described as follows: Lot 11 of Afton Airpark Addition to the Town of Afton, Lincoln county,
Wyoming as described on the official Plat No. 167 -C filed August 1, 2005 as Instrument No.
910442 of the records of the Lincoln County Clerk.
Leslie Morehouse, being of lawful age and having been first duly sworn according to law,
2. That said Warranty Deed was filed in the office of the County Clerk and Ex-
Officio Register of Deeds for Lincoln County, Wyoming, on the 28th day of September, 2005,
and duly recorded in Book 599 at Page 390.
3. Brad Morehouse and Leslie Morehouse were lawfully married at the time of said
Warranty Deed and were expressly designated in said Warranty Deed as husband and wife, as
tenants by the entirety.
4. That Brad Morehouse, one of the Grantees in said Warranty Deed and husband of
the Affiant, died in Reno, Nevada, on the 13 day of September, 2007, and left surviving, his
widow, Leslie Morehouse, who was named as the other Grantee in said Warranty Deed.
5. That the death of said Brad Morehouse terminated his previous estate in the real
property described in said Warranty Deed, leaving Leslie Morehouse as the sole surviving joint
tenant.
6. That attached hereto and made a part hereof is a certified copy of the Certificate of
Death of Brad Morehouse; and that Bradley D. Morehouse named in said Certificate of Death
was one and the same person as Brad Morehouse named in the Warranty Deed described herein;
and that Leslie Morehouse, named in said Certificate of Death as the Wife is one and the same
person as Leslie Morehouse named in the Warranty Deed described herein.
DATED this
7. That this Affidavit is made pursuant to the provisions of WYO. STAT. 2 -9 -102.
day of December, 2010.
WITNESS my hand and official seal.
My Commission expires: 9 -/5-//
Leslie Morehouse
This instrument was acknowledged before me by Leslie Morehouse, this o Q0 day of December,
2010.
Notary Public
GLORIA K. BYERS
County of
Lincoln
MV COMM iAc
NOtARY PUBLIC'
State of
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f'111 WA HC�E CO UNTY' DISTRICT HEALTH DEPARTM r
VITAL: STATISTICS
Reno, Nevada
TYPE OR
PRINTIN s:>
PERMANENT
BLACi( INK
D
iF D
0OpURRED IN
INSTITUTION:
SEE HANDEQO,
"hEGARDING'°
GQMPLETIQN 9F
RESIDENCE"
ITEMS
DISPOSITIb
TRADE CALL
REGISTRAR
1
'CAUSE
DEATH
CONDI"rIONS.;(F.
;ANY WHICH'.
GAVE RISE TO
IMMEDIATE.'
5'1A1/ING;THE ••••i;
UNDERLYING;.
DAU$E LA ST`
CERTIFICATE OP DEATH
20070 7'24!3'
STATE FILE NUMBER.
1a. DECEASED NAME: F(RS.T
Bradley Daniel
1b.. MIDDLE
N
3b. CIT Ci TOWN,.()R. LOCATION OF..DEATH
Reno
5. RACE- (e.g., White, Black,
American Inttian);(Speclfy)
White
9a STAAE OF •BIRTH (If not i1.S A
namecauntry) allfo
13. SOCIAL SECURITY NUMBER
'15a. RESIDENCE :STATE
Wyoming
16. FATHER NAME (First :Middia Last Suffix')
Sidne MOREHOUSE
18a, INFORMANT- NAME (Type orPnti()
`Leslie lone MOREHIOLISt
19a BURIAL:; CREMATION iREMOVAL,'OTHER1Sper;ify)
emovai from State
20a. FUNERAL,DIRECTOR SLQNATURE (Or Person Acting as Such)
HOW:
S1GNA"TURE AUTHENTICATED;;
285. ACC. SUICIDE, HOM iJ,MDRT
OR PENDING INVEST. (Spedfy)
AC
29e:.INJURY ATWt 'RK (5peafy
Yes oP No) No
MOREKOU.SE
30 HOS O+HER INSTITUTION Name(If not either. give street
and number): Reno Stead'Aifpott
6. Was Decedent of`HispanioOrigin? No
If yes specify Mexican Cuban, Puerto Rican etc
Nonh
i sp e n l c
Pb. CITIZEN OF WHAT COUNTRY
Untied States
15.. COUNTY
Lincoln
10. EDUCATION
7a: AGE -Last
birthday (Years}
47
15.p C ITY :TOWN OR LOCATION
Afton
21 a. TO the best of my knowledge death occurred at the time date'and place and due
v A:'to#11e catige(s) (Signature &TMe)
21b DATE SIGNED(MolDay/Yr)
r z:
m 21d NAME OR ATTENDINGPHYSICIAN IF: OTHER'THAN CERTIFIER L.
w (Type or print)
21 c HOUR OF DEATH
24a
2. DATE OF DEATH (Mo(DayNear)
September 13 2007
7b.'1JNDER 1 YEAR
MOS I DAYS
11. MARRIED, NEVER MARRIED;
DIVORCED (Specify) M
wiDoWEO,
armed
1.4a USUAL.00CUPATION (Gtte Kind ofyy rk Done During Most of Working
Life Even If Retired)
Developer
17 MOTHER NAME :(First Middle Last Suffix)
}anet SEEKIN8
h8b. MAILING ADDRESS
Street t7r :R F D Np City or Town State. Zip)
P,0 Box l662 Afton Wyoming 83110;
190 CEMETERY OR CREMATORY NAME
Afton Cemetery
20b.FUNERAL
DIRECTOR 'LICENSE
622;
TRADE GALL NAMEANDAI)DRESS
Schwab F.�neraf Home 44 EastFoufth Afton WY 8311O:
23a. NAME AND AbDFRESS•OF C (PHYSICIAN ATTENDING PHYSICIAN; MEDICAL EXAMINER OR CORONER) (Type or Printy
Ell G PQBox 11130 Reno,;NV $9520
REGISTRAR LAURA D A NIELS
SIGIVATIIRE 'AUTHENTICATED
25 IMMEDIATE CAUSE (F1tTER ONIY ONE CAUSE PER LINE FOR (a) (b) ANp (c)
1 PART (a) Multiple blunt f orce'trauma
DhUE TO OR AS A CONSEQUENCE OF
DUE TO, •OR AS A •CONSEQUENCE bF:
26c HOUR;O I N J URY
28b':PAX OF1NJURY (MolDay/Y'r)
S eptember 4S 2007
28f'.PLACE'OF'INJURY At farm,: street factory; office
building etc.;(Spedify) ;Airport
3e If Hosp or Inat indicate pOA OPtEmei. Rm
Inpatient(SpecIfy)
7C: UNDER 1 .DAY>'
HOURS I MINS
19t1. ST.REET..AND NUMBER'
225 West Dlamrtnd,
20c. NAME AND ADDRESS 'OF FACILITY
Ross; Burke and Knobe} Mortuaiy Reno
2155 Ifietzke Lane ,Reno NV 89502
W 22a. Onitie basis of examinatiGn5ndlor investigation, in my:Dpiniort deatFl dccurred at
Q.ttikatirne, data and place and due to the ca
use s) state d (Signature
m Title)
ELLEN It�1.IrCLARK: M.D S..IGNATU AUTHENITICATED
<22c. FLOUR OF DEATH
1445
0
22b 'DATE SIGNED (MolDay/yr)
m.o September 18 2007
a 22d. PRONOUNCED DEAD (halo /OaylYr).,;,
September 13;`2007
24b.DATE.RECEIVED:BY
(MO /DaylYr)
September 20 2007
PART. OTHER SIGN IFICANT CONDf71ONS- Conns ditio contributing to#leath byt riot result rig in the underlying cause given n Part 1
3a. COUNTY OF DEATH;
Washoe
4 SEX
Male
8. DATE :OF BIRTH (MO/Day/Y0
October 07; 1959
12. SURVIVING' SPOUSE (ifwife give
maiden e
L s lOne MORRIS
14b
KIND OF BUSINESS OR INDUSTRY
Land
15e. INSISE CITY
LIMrrS (Specify Yes or
No) i: Y
19c. tACATION ':;City or T.ov✓n' State;:
Afton Wyoming 831 to
22e. PRONOUNCED PEAD:AT (Hour)
23b. ttCEI4SE NUMBER.
6850
240. DEATH DUE TO COMMUNICABLE DISEASE
YES NO
lnterYal between onset :and deatti
Interval between ohset'
26. AUTOPSY (Specify 27 WAS'CASE REFERRED
Yes Of No) TO CORONER (Specify Yes
Yes or Ne) Yes
2Sd DESCRIBE.HOWJNJURYOCCURRED
Pilot of atitraft (jet) that trashe
28g LOCATION STR QR R F D No
4895.Yezas Avenue
CITY OR TOWN STATE
Reno Nevada;
PARENTS
.CERTIFIER
STATE REGISTRAR
ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE
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iii.,, /i Ern
C ERTIFIED COPY OF VITAL RECORDS;'
This is a true'and exact reprodnetion of ttte document officially registered and
Placed on file.,in the office: t he State Registrar attd Vital ReeESr4s /1
DATE ISS()ED S E P :2 2 0( 7
DEPUTY `REGISIRARz
This copy nOt valid unless prepared on.engraved border displaying date seal and signature iif Regist
;i!VRS2Rev