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Home My WebLink About958041STATE OF WYOMING ss. COUNTY OF LINCOLN Part of Lot 1, of Block 20, of the Afton Original Townsite., of Afton, Lincoln County, Wyoming, as per the duly recorded plat thereof. More fully described as: Beginning at a point 5 Y. rods West of Northeast Corner of Lot 1 of Block t# 20 in the Afton Townsite, Lincoln County, Wyoming, and running th.ence West 4 rods, thence South 10 rods, thence East 4 V2 rods, thence North 10 rods to the place of beginning. The property is also known by the following street name and number: 74 E. Fourth Street, Afton, Wyoming. Affidavit of Sure: i‘orship Page 1 of 2 RECEIVED 2/11/2011 at 11:16 AM RECEIVING 958041 BOOK: 762 PAGE: 353 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY 003.1+ AFFIDAVIT OF SURVIVORSHIP I, MARCIA HARRISON, being first duly sworn, upon my oath depose and state: 1. That I am of the age of majority and competent to make this Affidavit. 2. That I am a resident of the Town o f Afton, County of Lincoln, State of Wyoming, and am the Affiant herein. 3. That by virtue of conveyances which are recorded in the office of the County Clerk of Lincoln County, Wyoming, as Instrument Number 753985, RONALD W. HARRISON and MARCIA HARRISON, husband and wife, are the record owners of the following described property: 4. Said RONALD W. HARRISON died on. the 4th day of October, 2008, at Idaho Falls, Bonneville County, Idaho, and a copy of the original certificate of death, notarized to as true and correct by the public record authority in which the original of said certificate is a matter of record, is attached hereto as Exhibit A. 000354 5. By reason of the death of said RONALD W. HARRISON, his interest and title in said Warranty Deed has terminated, and title to the real property conveyed thereby has vested in MARCIA HARRISON DATED this ,fig" day of January, 2011. STATE OF WYOMING COUNTY OF LINCOLN ss. The foregoing instrument was acknowledged before me by MARCIA HARRISON this 2.c' day of January, 2011. Witness my hand and official seal. CRYSTAL L. SLAUGHTER NOTARY PUBLIC County c Lincoln State of Wyoming My Comrnissior:. t;_xj?n i ebruary 3, 2014 My Commission Expires: Affidavit of Survivorship Page 2 of 2 MAR 'IA HARRISON 11/a NOTARY PUBLIC CERTIFICATION OF VITAL RECORD illy YISTATE REGISTRAR: State of Idaho CERTIFICATE OF DEATH STATE FILE NO. I I y IIVII li t i i I.. olA n cE N E a aaE Local Reg 917 c' y 7L 7 �i awl SM4lBE UaEDa N +raert EwDENCe Or r„aoE +ir, UOEe.F �9 ilel +up R9lrbn.DfApE 1. DECEDENT'S LEGAL NAME (Include AKA's d any) (First, Middle, Las, Suffix) 2. SEX I3. SOCIALISECURITY NUMBER II llw h II III Ronald Wayne Harrison 1 Male PniNT IN PERMANENT 01 4s AGE-Last Birthday 46. UNDER 1'VEAR 4c. UNDER 1 DAY 5. DATE OF BIRTH (MNDey/Yr) 16. BIRTHPLACE (Oily and Stale, Territory, nr Foreign Country) BLACK INK Months T Days R9urs I Mal U NOT USE 65 i` April 21, 1943 I Ogden, Utah FELTTP PEN 'D j, (Years) I.. FOR 55 7a. RESIDENCE STATE OR FOREIGN COUNTRY 7b COUNTY 7c. CITY OR TOWN INSTRUCTIONS': N Wyoming Lincoln 1 Afton SEE HANDBOOKS' 7d. STREET AND NUMBER 7e. APT. N0. 7f. ZIP CODE 1 79. INSIDE CITY LIMITS? 3 74 East 4th Avenue 83110 J Ix Yes r No I> 8. MARITAL STATUS AT TIME OF DEATH 9. SURVIVING SPOUSE'S NAME (II wife, give maiden name) PARENTS PLACE OF DEATH DATE OF DEATH CAUSE OF DEATH IT TO FOR EXTERNAL' CA USES ONLY U Ir CERTIFIER I IF DEATH WAS DUE TO OTHER THAN NATURAL CAUSES, THE 009ON58 M08I COMPLETE AND SIGN THE CERTIRCATE REGISTRAR ill' sza. lll�M9rfed Married,_bulSeparaled 0 Widowed 11 Divorced 0 Never married UUnknown Marcia Grow 10 EVER, IN U.S. 11a. FATHER'S NAME (First. Middle, Lest Suffix) 11b BIRTHPLACE (Stale, Territory. or Foreign Country) Rmtq 1p, R'ces? Wayne Earl Harrison Utah 1' den 12a. MOTHER'S MAIDEN NAME. (First, Middle. Last. SuSuffix) 12b. BIRTHPLACE (Slate Territory. or Foreign Country) o Rose Pratt Idaho 13a. INFORMAN S,NAME (Type or print) 13b. RELATIONSHIP TO DECEDENT 13c. MAILING ADDRESS (Street and Number, Clty, Stale Zip Code) Marcia'' „Harrison Wife P. O. Box 1012, Afton, WY 83110 Q_ 14. METHOD OF D75PpSITIOr 15. PLACE OF DISPOSITION (Name and address of cemetery, 16. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY 5 Burial 3.1Cremalion cremal0, etherDlace) Wood Funeral Home Cl D Ut lombmenl Eagle Rock Crematory P. 0. Box 51434 c c m g p Q 0 Other Other (Specify) Sp cify) o Id alto Falls, Idaho Idaho Falls, ID 83405-1434. 43 S URFl l( jTF�OF FUNERAL SERVICE LICENS R PERSON ACTING AS SUCH 7b. LICENSE PI -1 NUMBER (01 licensee) 118. WAS CORONER. CONTACTED. 1 1 �.()S DUE (l TO es USED )EN71 S TATE OF IDAHO DEPARTMENT OF HEALTH AND WE FARE BUREAU OF VITAL RECORDS AND HEALTH STATISTICS r print) annin I A'O �ORoperrs suese UE T SI NATUR F NECESSA Y. The 001 pM1,yardlen assistant, or arty aced prac e professional n ma, and Illhave iell�pWed and II necessary ed the medical secti• 41ai1R(:GISTRAR'S SIGNATURE RATE ISSUED: 0 2 h',Thisl8op is not valid unless prepared on engraved border dlsr Ying state seal and signature of the Registrar. PLAC O F DEATH (19.221 19a. IF DEATH OCCURRED IN A HOSPITAL 19b. IF DEATH OCCURRED SO EWHERE:OTHER THAN A HOSPITAL: t�t •lnpatient t I EIS/Outpatient ,0 DOA'. (,3- Hospice facility s[I Nursing home/Long term care racily a Decedents Some r[1 Otherl(Specly) 20. FACILITY NAME (If not facility. give street and number) 21. CITY, TOWN, OR LOCATION'. OF. DEATH, AND. ZIP CODE /1 22. COUNTY' OF DEATH Eastern ID Regional Medical Center Idaho Falls 83404 Bonneville 23. DATE OF DEATH (Mo/Dey/Yr) (Spell month) 24. TIME OF DEATH 25. DATE PRONOUNCED DEAD (Ma/Day/Yr) (Soell month) 26. TIME P$ONOUNCED DEAD October 4,, ;2008 1217 (204 October 4, "2008 1217 (2(200 Z/. UAU0E OF UEAI H PART I. Enter the plt8[I( jf evanlo- -disep es li I Ras „o compkcabons 1091 directly caused the death. DO NOT enter terminal events such as cardiac App o Image 101. rvsl arrest respi tory arre t, orlle Ircu,er fb aUo Ihoul•sho In the enotogy NOT ABBRE (ATE. Ente only one use o I ne Onset 1013051 IMMEDIATE CAUSE (FTbel a C y� j<7 4 w l vaY.r ,,s disease or condition resullirgin death) DUE TO can •9 N� Sequentially fist condition b e. S t C r S 1 1Z uwke.. 4 b l f' rC 5 IL� 1111 B y leading to the cause DUE TO for as a cen,e9u ce 011: �I Ils ti (adlbnlline a Enter the UNDEFi CAUSE 4. 11\ ,LAST ((080000 or I Jury I COE TO canae9 a„ce D0: II es,, Ih 1 Intuited the events II r i YIll4lin d ath) d I rip PART II: Enter other sion(licanl conditions cnnlnbubno to death but not resulting to the underlying cause given in Pan I 280, WAS AN AUTOPSY 28b. WERE AUTOPSY FINDINGS PERFORMED? AVAILABLE TO COMPLETE O X THE CAUSE OF DEATH? N 29. DID TOBACCO USE, (Aged IF FEMALE Aged 10 -54)• ❑Yes X] No 1 Yes =l No r 31. ANNER OF DEATH CONTRIBUTE TO UEATH7 r1 :0 N 1 p 69nent within past year 13 NW pregnant. but pregnant 43. days (1 Pr gn 1 I time of death to )"yea before death lu al W micde Ves Proli'ably Accident i1 P do 1 1 Li bi t p g nl „bul•pregnant 0 l Unknown (pregnant within the pass I 9 nvas ga ion SP. Unk(oy *iron 42 daysol death 11091 0 Suicide 'J Could not be determined ITEMS 32 -3B 0 3 DATE OF INJURY (MO/Dey/Vr) 33:' TIME OF INJURY. 34. PLACE OF INJURY (Decedent's ho: ,farm, street. construction silo, 35. INJURY AT WORK? BE USED E (Spell month) nursing home restaurant, forest. etc.) Yes No 1 O OPO'Jf H) 3¢ 1 1 1 0CATON OF INJURY: dae l (24M1r City/Town or County Zip Code I11t MI ill IIII LL Stra Number or Location Apanm nl Number ��l 3T DES (BE HOW INJURY OCCURRED IF TRANSPORTATION INJURY, STATE THE TYPE(S)' OF VEHICLE(S) INVOLVED (Automobile. pickup: motorcycle, ATV bicycle, tc.) ii W I SP E, bIFY WHICH VEHICLE DECEDENT OCCUPIED. II applicable V TRANSPORTATION X 389. WAS DECEDENT: riverlOp. alor TT Passenger 99. HAT FETY DEVICE(S) DID DECEDENT USE/EMPLOY? ,,,INi(UFP ONLY Pedeelrl4h ❑O '1 (Specity) Seel Bell 00114 salary seal p Helmet DAir bag 1None L lUnkho 39a. CERTIFIER (Ch0Ckjronly .0%0. o 0 1,1 capeclly for 1 is ce 1icale) 39b. LICENSE NUMBER IUt PHYSICIAN f 1 V IAN ASSISTANT 0 A NCED PRACTI• PROFES' ONAL NURSE To the best of my knowledge) d h occurred al Ina lime, d e, an place d due to the r 0069 sonar stated. #M-4522 CORONER 39c�,4TE SIG: i On !he beak of exam R to tl /or investigation, in my •ini•n, occurred at the ti m: e, end place, a causes) and ginner staled. Signature and Title of Certlf1 39d. NAME, ADDRESS,. AN 7' IP CODE OF CER Dr.,;,,,Kenneth E R (Type 200 'C 208535 -4300 a 40205, Idaho Falls, Idaho 83404 40b. DATE SIGNED s signature this item supersedes that of the physician, coroner becomes the cenillerr of record. This is a true arid reproduction of the document officially registered and placed on file with the'IDAHO'!'3uREAU OF VITAL RECORDS AND HEALTH STATISTICS. MM DD' YYYY MM DD 41b. DATE SIGNED /0, /2 s MM DD 0400 JANE S. SMITH STATE REGISTRAR •saca .un tyro(.'