HomeMy WebLinkAbout9582966011119832
STATE OF
U°
COUNTY OFd..G,✓IC:VCwv
SS.
AFFIDAVIT TERMINATING ESTATE
I, 2 74ari /f. r being of lawful age and first duly sworn
according to law, upon my oath, depose and state:
1. That I am of adult age, a resident of ez)edeldi-Ze and the
Affiant herein.
2. That by virtue of the conveyance which is recorded in the office of the
County Clerk for Lincoln County, Wyoming, located at Kemmerer,
Wyoming in Book 36g PR on page -/r0 is recorded a
Warranty Deed. The Warranty Deed dated the l- day of
14
99�' conveys unto
r L 6 e Q 4d m. d Husband and Wife as Tenants by
the Entireties with full rights of survivorship the following described
property, to -wit:
See attached Exhibit "A"
3. That said gZe/IA f 4(7' s" on the y day of
E' bee- c.D20p9, died and a copy of the original
certificate of death, certified to as true an correct by public authority in
which the original of said certificate is a matter of record, is attached
hereto as Exhibit "B
4. That by reason of death of said
2 -9 -102 W.S. (1980), the decedents
has terminated and title to the real
absolutely in E 1Qr irk-Z(4p
of the said decedent.
FURTHER AFFIANT SAYETH NOT.
Dated C:
State of a
f� )ss.
County o f� e4Aivie
The foregoing instrument was subscribed
c= fte. r this Ar day of
Witness my hand and official seal.
My Commission Expires: 9 0
JILL H. LARSON
Count; of
Lincoln l
O ARY PUBLIC
date of
Wyoming
Ally Commission r 3.. ;?fifes June 20, 2(311
y�4��4' �k' v4�' Id4GR* ylIA�QM�d... C •''VwWW'QGi�^�wSAY.F'�+1&Yx'AS VM":4u`4''.r�,:
RECEIVED 3/1/2011 at 2:24 PM
RECEIVING 958296
BOOK: 763 PAGE: 223
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
by reason of
interest and title in said conveyance
roperty conveyed thereby has vested
ej' continuously since the death
000223
and sworn to me by
5? /1
Ci
41
is
Notary Pub
Order No: 6011119832ET
LEGAL DESCRIPTION
EXHIBIT `A'
000224
Part of Tract 83, Township 24 North, Range 118 West of the 6th P.M., Lincoln County,
Wyoming, said part being more particularly described as follows: Commencing at a point
on the East line of said Tract, North 0 °44'00" West 420.48 feet from corner number 4 of
tract 90 in said township, said point also being on the North line of First North Street as
shown on the map of the Collett First Addition to the Town of Cokeville; running thence
North 89 °10'00" West 261.00 feet along the North line of said street; thence North 0 °44'00"
West 230.00 feet; thence South 89 °10'00" East 257.00 feet; thence South 18 °35'33" East 7.80
feet; thence South 0 °44'00" East 223.90 feet to the point of beginning.
ERTIFICATION OF VITAL RECORD
DECEDENT LEGAL NAME
MARITAL' STATUS AT TIME OF DEATH
MARRIED
FATHER NAME
VERNON J BECK
MOTHER MAIDEN NAME
AGNES M COLBIN
METHOD OF DISPOSITION
REMOVAL FROM STATE
1 NAME AND ADDRESS OF FUNERAL FACILITY
MATTHEWS MORTUARY,
DATE'AF INJURY
LOCATION WHERE INJU OCCURRED
SOCIAL SECURITY NUMBER
FLORIDA
FUNERAL SERVICE LICENSEE
TIME OF INJURY
STATE OF IDAHO
DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
57 YEARS
DAVID N. MATTHEWS
INC., MONTPELIER, IDAHO
PLACE OF RESIDENCE
NAME OF SURVIVING SPOUSE (If eife, maiden. name)
IDA MARIE PEARSON
NAME OF CERTIFIER.
MICHAEL L. FRANCISCO, M.D.
CORONER SUBSEQUENT CERTIFICATION IF NECESSARY
State File No. 2009
DATE OF BIRTH
SEPTEMBER 27, 1952
COKEVILLE, WYOMING
PLACE OF INJURY
JANE S. SMITH
STATE REGISTRAR
BIRTHPLACE
COLORADO
BIRTHPLACE
ALABAMA
TITLE
PHYSICIAN
WAS DECEDENT EVER IN
U.S. ARMED FORCES?
YES
DATE OF DEATH TIME OR DEATH CITY,TOWN OR LOCATION OF DEATH COUNTY OF DEATH
DEC. 30, 2009 5:25 P.M. POCATELLO, IDAHO BANNOCK
CAUSE OF DEATH (underlying cause last) Approximate and oeateJal Between
a LUNG CANCER 10 -13 MONTHS
DUE TO (or as a consequence of):
b.
DUE TO (or as a consequence of):
c.
DUE TO (or as a consequence of):
d.
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH but not resulting in the underlying cause given above Was AN AUTOPSY
PERFORMED?
NIf1NF� STATFfl NO
INJURY AT
WORK?
DESCRIPTION OF HOW INJURY OCCURRED
.h
PA
WC IN IN BMW IMO IP 1 Ilan
This is a true and correct reproduction of the document officially registered and placed
on file with the IDAHO BUREAU OF VITAL RECORDS AND HEALTH STATISTICS.
JANUARY 12, 2010
DATE ISSUED:
This copy is not valid unless prepared on engraved border
displaying state seal and signature of the Registrar.