HomeMy WebLinkAbout958441STATE OF\N,\. \WC1(
)SS.
COUNTY O vtic
FURTHER AFFIANT SAYETH NOT.
Dated: ,2011
State of Wyoming
)ss.
County of Lincoln
Witness my hand and official seal.
My Commission Expires:
AFFIDAVIT TERMINATING ESTATE
USA M. SPAULDING NOTARY PUBLIC
State of
Wyoming
County of
Lincoln
My Commission Expires June 1, 2011
RECEIVED 3/11/2011 at 11:26 AM
RECEIVING 958441
BOOK: 763 PAGE: 616
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, Bill R. Brewer, being of lawful age and first duly sworn according to law, upon my oath, depose and
state:
1. 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 714 on page 750 is recorded a QuitClaim Deed. The
QuitClaim Deed, dated the 4th day of February, 2009 conveys unto
Bill R. Brewer and Gina Brewer as Husband and Wife.
the following described property, to wit:
000616
Lot 19 of Lincoln Third Addition to the Town of Afton, Lincoln County, Wyoming as
described on the official plat file on November 30,2006 as instrument No. 924889 of the
records of the Lincoln County Clerk.
2. That said Gina Brewer died on the l' day of Oe` a`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
The foregoing instrument was subscribed and sworn to me by Bill R. Brewer,
This day of `\\kta\ 2011
CERTIFICATI 1 ITAL RECORD
CERTIFICATE OF DEATH
Date Filed OCTOBER 21, 2009
DECEDENT LEGAL NAME
GINA JOHNSON BREWER
SIX SOCIAL SECURITY NUMBER AGE DATE OF BIRTH
FEMALE 45 YEARS SEPTEMBER 03, 1964
BIRTHPLACE PLACE OF RESIDENCE
AFTON, WYOMING AFTON, WYOMLNG
MARITAL STATUS AT TIME OF DEATH NAME OF SURVIVING SPOUSE (If wile, maiden name)!; WA U.S S ARMED FOR DECEDEM CES EVER IN
MARRIED BILL RHAR BREWER. NO
FATHER NAME
BIRTHPLACE
FARRELL ,D. JOHNSON WYOMING
MOTHER MAIDEN NAME BIRTHPLACE
NAOMI GAYS TAYLOR WYOMING
REMOVAL FROM STATE
NAME AND ADDRESS OF FUNERAL FACILITY
NALDER'S FUNERAL HOME, SHELLEY, IDAHO
DATE OF DEATH TIME OF DEATH I CITY,TOWN OR LOCATION OF DEATH GAUNT? OF DEATH
OCT. 18, 2009 7:56 P.M. IDAHO FALLS, IDAHO BONNEVILLE
CAUSE OF DEATH (underlying cause last) Approximate Interval Between
a. Onset and Death
MULTIPLE ORGAN FAILURE,
25 DAYS
DUE'TO (or as a consequence of):
b.
CARDIOGENIC SHOCK AND SEPTIC SHOCK 25 DAYS
DUE TO (or as a consequence of):
`CARDIAC ARREST WITH RECURRENT VENTRICULAR FIBRILLATION 25 DAYS
DUE TO (or as a consequence of);
d CORONARY ARTERY DISEASE 30 DAYS
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH but not resulting in the underlying cause given above WAS AN AUTOPSY
;PERFORMED?
DIABETES MELLITUS, COAGULOPATHY, ATRIAL FIBRILLATION NO
MANNER OF DEATH ',NAME OF CERTIFIER TITLE
NATURAL DOUGLAS N. WHATMORE', M.D. PHYSICIAN
CORONER SUBSEQUENT CERTIFICATION IF NECESSARY
DATE OF INJURY
TIME OF INJURY
MAO
Ir PLACE OFD INJURY'.
INJURY AT
WORK?
LOCATION WHERE INJURY OCCURRED
DESCRIPTION OF HOW INJURY OCCURRED
DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
UNLHAL JblNICE LICENSEE
JASON P. MECHAM
OCTOOER 21, 2009
DATE ISSUED•
This copy is not valid unless prepared on engraved border
displaying state seal and signature of the Registrar.
STATE OF IDAHO
This is a and correct reproduction of the document officially registered and placed
on file with the IDAHO BUREAU OF VITAL RECORDS AND HEALTH STATISTICS.
JANE S.. SMITH
STATE REGISTRAR
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