HomeMy WebLinkAbout957812Upon Recording Please Return To:
James R. Baker, LC
7109 S. Highland Dr, #201
SLC, Utah 84121
Yihlin Chan
2345 Cliff Swallow Dr.
Sandy, Utah 84093
AFFIDAVIT OF CO- TRUSTEE
I, Yihlin Chan, Affiant, do hereby solemnly swear and aver as follows:
1. That I was the husband of Ing -Fong Chan and that I was her principle beneficiary.
2. That Ing -Fong Chan died December 19, 2010, as evidenced by the death certificate
attached hereto and by this reference made a part hereof.
3. That Ing -Fong Chan, is one and the same person as the person shown in the attached
death certificate.
4. That Ing -Fong Chan, died being a Co- Trustee with the Affiant, Yihlin Chan, in a parcel of
real estate in Lincoln County, which Co- Trusteeship is hereby being terminated in favor of Affiant,
Yihlin Chan, Trustee, in this parcel of real estate, which was recorded in Lincoln County,
Wyoming on July 19, 1990, with Recording No. 720383 in Book 278PR, Page 484 and is more
fully described in the Records of Lincoln County, Wyoming as follows:
State Of Utah
STAR VALLEY RANCH PLAT TWENTY -TWO (22) LOT FOUR (4) AS PLATTED AND
RECORDED IN THE OFFICIAL RECORDS OF LINCOLN COUNTY, WYOMING
Further Affiant saith not.
ihlin Chan, Affiant, Trustee
County Of Salt Lake
Subscribed, sworn to and acknowledged before me Yihlin Chan, Affiant, Trustee, whose
identity is kn wn to me or proven on the basis of satisfactory evidence,
This „2b ay of 20
ss.
JAMES R. BAKER
Notary Public State of Utah
My Commission Expires on:
June 1, 2013
Comm. Number: 578910
RECEIVED 1/27/2011 at 10:18 AM
RECEIVING 957812
BOOK: 761 PAGE: 438
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
pires:
000438
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CERTIFICATION OF VITAL RECORD
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DECEDENT INFORMATION
Date of Death: December 19, 2010
City of Death: Salt Lake City
Age: 62
Place of Birth: Taiwan
Armed Services: No
Spouse's Name: Yihlin Chan
Industry/Business: Government
Residence: Sandy, Utah
Mother's Name: Yu -Tse Wang -Chen
Facility or Address: Univetsity of Utah Hospital
INFORMANT INFORMATION
Name: Yihlin Chan Relationship:
Mailing Address: 2345 Cliff Swallow Drive, Sandy, Utah 84093,
DISPOSITION INFORMATION
Method of. Disposition: Cremation
Place of Disposition: Lake Crematory, Sandy, Utah
Date of Disposition: December 20, 2010
FUNERAL HOME INFORMATION
Funeral Home: Lake Hills Memorial Mortuary
Address: 10055 South State, Sandy, Utah 84070
Funeral Director: Matthew C Yardley
MEDICAL CERTIFICATION
Medical Professional: John Robinson Singleton M D, 50 North Medical Drive, Salt Lake City
Date Issued: January 18, 2011
e -&„4,
Barry E. Nangle
CERTIFICATE OF DEATH
State File Number: 2010014516
Ing -Fong Chan
Time of Death:
County of Death:
Date of Birth:
Sex:
Marital Status:
Usual Occupation:
Education:
Father's Name:
Facility Type:
Husband
11 1 2 11111 3 119
03:07
Salt Lake
November 17, 1948
Female
Married
Chemist
Doctorate Degree
Yih Liu
Hospital Inpatient
000439
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an This is a exact reproduction of the document registered in the State Office of Vital Statistics.
Security features of this official document include: Intaglio Border, V R.images in top cycloids,
ultra violet fibers and hologram image of the Utah State Sep!, over the words "State of Utah
This document displays the date, seal and signature of the State Registrar. of Vital Statistics.
(Salt Lake), Utah 84132
CAUSE OF DEATH
Ventriculostorny Failure
Due to (or as a consequence of): lschemic Encephalopathy
Tobacco Use: Non -user
Medical Examiner Contacted: Yes. Autopsy Performed: Yes Autopsy Available: No Manner of Death: Natural
UTAH DEPARTMENT OF HEALTH
Office of Vital Records Statistics
Salt Lake City, Utah
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