HomeMy WebLinkAbout959056Affidavit of Survivorship
I, Roice L. Jackson, being of lawful age and duly sworn according to law, upon my oath,
depose and state:
That under the date of May 24, 2002, for valuable consideration, Atha Crook Jackson,
Trustee of The Jackson Family Trust dated February 17, 1999, by deed of that date, which deed
was duly filed of record in the Office of the Lincoln County Clerk, on May 30, 2002, in Book
490PR, Page 691, conveyed to Roice L. Jackson and Linda L. Jackson, Husband and Wife, the
following described land, in the County of Lincoln, State of Wyoming, to -wit:
A portion of the S1 /2SW1 /4 of Section 35, T35N R119W of the 6th P.M., Lincoln County,
Wyoming, being more particularly described as follows:
BEGINNING at a point 1275.694 feet East and 432.021 feet N4 °1o'33 "W from the Southwest
corner of said Section 35;
thence N6°24'39"E, 105.165 feet;
thence S87 °23'11 "E 481.601 feet;
thence S8 °19'41 "W, 128.017;
thence N84 °41'o8 "W, 476.348 feet to the point of beginning
That by reason of said conveyance aforesaid, the said Roice L. Jackson and Linda L.
Jackson, Husband and Wife, 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 Linda L. Jackson,
also known as Linda Lee Jackson, on the 22nd day of July, 2007. That by reason of and upon the
death of Linda L. Jackson, title in the above described real property vested in Roice L. Jackson.
Affiant avers and certifies that Linda L. Jackson, also known as Linda Lee Jackson, is the
identical party named with Roice L. Jackson in the aforementioned deed, whose death terminated
her 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.
Dated this i I day of ,>tf G h 2011.
State of LOrk t
ss.
County of Li p t v
WITNESS my hand and official seal.
My Commission Expires: 2- 10 N
y
RECEIVED 4/25/2011 at 4:35 PM
RECEIVING 959056
BOOK: 765 PAGE: 832
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
e‘' c
4
Roice L. Jackson
Subscribed and worn to before me, a notary public in and for said County and State, by
Roice L. Jackson, this 11 day of N1 Aiz.�� 2011.
Notary Public
USA STOUDT NOTARY PUBLIC
County of 'C State of
Lincoln Wyoming
Commission Expires August 10, 2014
1
DECEDENT INFORMATION
July 22, 2007
Salt Lake City
\65
Escanada, Michigan
No
Roice LaVard Jackson
Cheese Manufacturing
Freedom, Wyoming
Bernettie Caroline Peterson
University of'Utah Hospital
Date of Death:
City of Death:
Age:
Place of Birth:
Armed Services:
Spouse's Name:
Industry/Business:
Residence:
Mother's Name:
Facility or Address:
INFORMANT INFORMAT
Name:
Maillhg,Address:
DISPOSITION INFORMATION
Method of Disposition: Burial
Place of Disposition: Freedom Cemetery,, Freedom, Idaho
FUNERAL'I OME INFORMATION'
Funeral'Home: Goff Mortu
Address: 8090 South 'Midvale, Utah 84047
Funeral Director: Del Ballard
DATE, ISSUED: July 23, 2007
MEDICAL CERTIFICATION
Certifying Physician: Richard H Schmidt
CERTIFICATE OF DEATH
State File Number: 2007008117
Time of Death:
County of Death:
Date of Birth:
Sex:
Marital Status:
Usual Occupation:
Education:
Father,'s'Name:
Facility Type:
Roice LaVard .Jackson Relationship:
231 Cedar Creek Road, Freedom, Wyoming 83120
22:45
Salt Lake
December 6, 1941
Female
Married
Cheese Packaging
High School or GED
Hjalmar Emanuel Olson
Hospital Inpatient
Date of. Disposition: July 28, 2007
1111111111111!0111111
D, 50 iVorth "Drive, Salt Lake City Utah 84132
CAUSE OF DEATH
Cerebellar hemorrhage fhern 18 Hours
Thrombocyto'penia [Onset 1; Moith]'
Aplastic anemia [Onset: 1 Month]
Seizure disorder f.
Tobacco Use: UnknoWn if User
Medical Examiner Contacted: No Autopsy Performed: No "'Manner of Natural
This is an 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 a hawk otter the word valld,This document displays the
date, seal and signature of the State Registrar and the County /District Health Officer.
Updated Utah ;State Seal replaces hawk over valid for authenticity.
Gary& Edwards
Director /Health Officer
County /District Health Department