HomeMy WebLinkAbout958381Affidavit of Survivorship 04)&380
I, Lisabeth Potter, being of lawful age and duly sworn according to law, upon my
oath, depose and state:
That under the date of January 28, 2003, for valuable consideration, George A.
Amussen, as sole owner, by deed of that date, which deed was duly filed of record in the
Office of the Lincoln County Clerk, on January 31, 2003, in Book 511PR, Page 428,
conveyed to George A. Amussen and Lisabeth Potter, as joint tenants, the following
described land, in the County of Lincoln, State of Wyoming, to -wit:
Lot 3 of the El -Jean Estates Subd.ivision, Lincoln County, Wyoming according to the
official plat thereof
That by reason of said conveyance aforesaid, the said George A. Amussen and
Lisabeth Potter, as joint tenants, became the owners of said real property, and the title
thereto vested in them continuously from the date of said conveyance, to the date of
death of George A. Amussen, also known as George Arthur Amussen, on the 24th day of
November, 2010. That by reason of and upon the death of George A. Amussen, title in
the above described real property vested in Lisabeth Potter.
Affiant avers and certifies that George A. Amussen, also known as George Arthur
Amussen, is the identical party named with Lisabeth Potter in the aforementioned deed,
whose death terminated his interest, title and estate in said real property; and Affiant
attaches hereto, and makes a part of this affidavit, a copy of the Official Certificate of
Death of said decedent, duly certified by the public authority in which said death
certificate is a matter of record.
Subscribed and sworn to before me, an�otary public in and for said County and
State, by Lisabeth Potter, this y day of
Dated this 'y day of 2011.
WITNESS my hand and official seal.
CARRIE TAYLOR NOTARY PUBLIC
County of
Lincoln
My Commission Expires:
RECEIVED 3/7/2011 at 2:35 PM
RECEIVING 958381
BOOK: 763 PAGE: 380
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
ss,
State of
Wyoming
My Commission Expires
2011.
Lisabeth Potter
x CERTIFICATIO ITAL RECORD
Date Filed DECEMBER: '02.,
l DECEDENT.- LEGAL NAME
GEORGE ARTHUR:;AMU.SSEN,
MALE
BIRTHPLACE
SAL„T:LAKE CITY UTAH
MARITAL: STATUS AT TIME OF DEATH
WIDOWED.
FATHER -'NAME
GEORGE AMUSSEN, SR
MOTHER.;:MAID f4WM
MAUDE "ANDERSON`
METHOD: OF DISPOSITION
REMOVAL FROM STATE
NAME AND ADDRESS OF FUNERAL FACILITY
BUCK MILLER- HANN`F:UNERAL
DATE OF DEATH
NOV: 24, 201:0
CAUSE OF DEATH (underlying cause last)
a
DUE TO (OCas a :consequence;of)i
b PULMONARY H Y P ER.TENS I.ON
DUE TO (Ot'as a consegUance:of):
VALVULAR HEART DISEASE
DUE TO (or :as a; consequence of):
d.
SOCIAL SECURITY NUMBER
FUNERAL SERVICE LICENSEE'
KEV IN K.;.. BODTLY.
HOME,. IDAHO FALLS, IDAHO
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO. DEATH but noi ihiheunderlying cause given above
OBSTRUCTIVE;PUtMONARY DISEASE RECURRENT ASPIRATION
MANNER OF DEATH
'DATE OF INJURY
:LOCATION WHERE. INJURY' OCCURRED
DESCRIPTION OF HOW INJURY OCCURRED
CORONER :SUBSEQUENT.CERTIFICATION'IF NECESSARY
TIME OF INJURY
DATE OF BIRTH
:JANUARY 05, :1:926
PLACE OF:RESIDENCE
THAYNE, WYOMING,
NAME OF SURVIVING SPOUSE (If Kile, maiden name)
NAME OF CERTIFIER
MICHAEL H. DENVER,
tk
BIRTHPLACE
UTAH:
BIRTHPLACE.
UTAH
CITY,TOWN:OR LOCATION OF DEATH
YEARS
YEARS
WAS DECEDENT EVER IN
U.S. ARMED FORCES?
YES
COUNTY OF DEATH
BONNEVILLE
Approximate Interval Between
Onset and Death
MONTHS
WAS ANAIJTOPSY
PERFORMED?
NO
PLACE OF INJURY
INJURY AT'
WORK?:°
STATE OF IDAHO
STATE OF IDAHO
IDAHO DEPARTMENT OF HEALTH "AND WELFARE-
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
CRTIFICAT. OF;DEATH..
This, is a true' and correct reproduction of the ddiument offlClall registered atii7 placed
on file with the IDAHO VITALRECORDS ANCI:HEALTH.STATISTICS..
JANUARY 24, 2011
'DATE: ISSUED:
This copyriot valid unless prep on ehgfaved boik er t'
display:(ng" state seal antlsignafure the Registrar.
PBNCOB5N07/10
JAMES B °AYDELOTTE
STATE:REGISTRAR
tiY r.., 1..1,.1+ •.e
2010-10126
ALI
OVA
AL
LI
p