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SINCE 1904
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RECEIVED 1/25/2011 at 2:41 PM
RECEIVING 957788
BOOK: 761 PAGE: 370
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT
000 370
I, Daniel J. Woolwine, being first duly sworn on oath, depose and say:
That I am a citizen of the United States of America over the age of 21 years, and a
resident of Wyoming.
That I was well and personally acquainted with Kristen D. Woolwine, in that certain
Warranty Deed dated August 27 2003 and recorded in Book 533, at Page 451, as Filing
No. 893091 in the office of the Recorder of Lincoln County, Wyoming.
That I know of my own knowledge that Kristen D. Woolwine in the said deed and
mentioned in the attached Certified Copy of Certificate of Death was one and the same person.
This affidavit is intended to terminate the ownership of said in the following described
property:
Lot 49 of River Ranches Fishing and Equestrian Estates at Freedom, Wyoming, according to that
plat filed November 16, 1994 in the Office of County Clerk, Lincoln County, Wyoming as
instrument No. 793710, Plat No. 351.
Tax Roll No. 3519- 271 -00- 207.00
Dated this 18 day of January 2011 A.D.
Daniel J. Woolwine
State of Wyoming
County of Teton
S S
Commission expires:
Residing in: C
INDIVIDUAL ACKNOWLEDGMENT
Notary Pu.lic
000371
On the 18 day of January A.D. 2011 personally appeared before me; Daniel J. Woolwine
the signer of the within instrument, who duly acknowledged to me that he executed the same.
PENNY DYKES NOTARY PUBLIC
COUNTY OF STATE STATE OF
TETON WYOMING
MY COMMISSION EXPIRES: 8 27 2014
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I oIIIpI 1.Decedents Legal Name(Include AKAs if any)(First Mid le, LAST, suffix) 2. Sex 3. Dale of Deolh (Mo /Day/Year)
KRISTEN DENISE WOOLWINE Female December 30, 2010
4. Social Security Numb 5as `Age 5b, Under 1 Year 5c. Under 1 day- 6. Date of 13irth(lrto/Oay/Year) 7. Birthplace(Cily and Slate or Foreign Country}
(Yers) Months Days Hours Minutes December28 1974 PARMA, OHIO
a. Residence State 8b. County 8c, City or Town
WYOMING LINCOLN FREEDOM
8d. Street and Number 8e. Apt. No. 8. Zipcode 8g. inside City Limits?
149 RIVER RANCH LOOP 83120 No
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9. Ever in US Armed Forces? 10. Marital Slalus at Time of Death 11. urvivinQ Spous Name (If wile, ve name pn flram
2 Decedenl'sEducatton Nettled 13,DecedemofHispenic Origin NIEL JEr� D4 D c INE illl!ii�lllil lyllu III III;11 IIINII�(Ilr 7IIIIIIjIIj
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w 17a. Inform�nt's Name 17b. Relationship to Decedent 170. Mailing Address (SI'r7 I' 0114 Nombor,'City. Stale, ZI
=a DANIEL J. WOOLWINE Souse P.O. BOX 13644
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II pt nil „I� 9n r Ora I "i 1 ee or Oth gent 20. License Number (of licensee) 21Q Name and Complete A��dd TO
ress of FurVeral F eciafy
ql 22a. Meth I f D IPIId IoW !��,I, 00 6243
Disposllion J O N S ON RC 1'4FU
Cremation J& asZC� f
2c, aca,o tepee t on ame o metery, rematory, or other ace 22d. Locatio (Cily/Town and State) 9819 DARROW RD
OHIO A VAULT WORKS CREMATORY VALLEY VIEW, ON TWINSBURG, OH 44087
egrslras ignalure ale Filed
26a. Noma of Person )ssumg Buf161 Perm t 5b. Istf7G1 0. 25c. Date Surlal Fermit Issued
YARISHLYNDA'" 180 9 3 eels
26a. Cannier 1 Certifying Physician
(Chadt only Of e) To Iho Ix>stof an knovA
y edge, death oowrrod al the limo, date, and place; and due to the use(s) W1d manner s(aftd/IIII!i'li I I 1 I II y I I IIII If i
1 Coroner .I'' PiI 11111111111 IIIIII I uIIQllllll {Illld
On ew baste of oxaminagon etW(o( Invasiigatlon, in my optnbn death occuued al Iho oink dale anf) pfAco ar>{f d Al l l�h die) a Il iaal T or sIq� tl I�IIIIh�IIh II i i
b. Time of De th 26c. Oate Pronounced Dead o //Year y Da 26d a Icase rL a o IIII III 1
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26 e. Signature and Tlll f ertifler 26f. Ucense number 26q IiI 111111II' 'VI I I i ^IIII�IIIIII�II (IIIIIIIIII I �Iy'II�I�II �Ihpp
r-'' 35,093467 i I I�III�I 2. „I�,o��lllu�IJI V
27. Name (Last. 9 n Ei Mid"die)and A dres Consequence. of) s of Person who Completed Cause of Death
KHAN, MOHAMMED AHMED, 9500 Euclid Ave. CLEVELAND, OH 44195
art
IIIW p p or a comp p lea ens iat catw o e 0 er e o y ng. su such as oar ac or ra ry sp r o arroet, we or laar a ore is Approximate nterva
I I�' o �Ib Ff to es, na Type ar plot in pennanart bitty or black ink. li r% r /,9tween Ont andDeat�' dletd I I nl I III �,Il f(v �2 c. .S cv p G I tee L Q C o-
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ar a gn Den Don oneeon r u ng to oat ut,not reeulang,in he under y ne emueogvon in an 29a. Was An Autopsy 29b. Were Autopsy findings..
Performed? Available Prior To Completion Of
Cause of Death?
Yes .No [Yes No Not Applicable
l Tobacco Use ontr bolo to oath? 31. if emote, Pregnancy Status 32. Manna o Deat
of pregnant within past year Natura l omicid
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No. Prob Not regnant, but re nant 43 da s to 1 ear before death Suicide III i 1 1 1 1 I I I�I�II�III OIII�II ate IIII I d T ill I l i
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3a: Date of Injury (MolDayIYear) 33b. Time of Injury 33c. Place of Injury (e.g., Decedent's home, construction site, restaurant' woorla (oalll IIIII H Injljll I 1 Wo II j1 IjIlllli l h)pI, 11 1� I�IIbI11� �i'
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