HomeMy WebLinkAbout959126County of
Dated this
day of
State of 1
ss.
WITNESS my hand and official seal.
My Commission Expires:
4.
NOTARY PUBLIC
VALERIE NARDONI
404 East 5800 South
Murray, Utah 84107
My Commission Expires
March 29, 2012
STATE OF UTAH
Affidavit of Survivorship
I, Ann Simpson, being of lawful age and duly sworn according to law, upon my
oath, depose and state:
That under the date of August 2o, 2006, for valuable consideration, Robert O.
Byam, by deed of that date, which deed was duly filed of record in the Office of the
Lincoln County Clerk, on September 12, 2006, in Book 633, Page 547 conveyed to Ralph
Simpson and Ann Simpson as Joint Tenants, the following described land, in the County
of Lincoln, State of Wyoming, to -wit:
Lot 57 of Star Valley Ranch RV Park Plat One as platted and recorded in the Official
Records of Lincoln County, Wyoming
That by reason of said conveyance aforesaid, the said Ralph Simpson and Ann
Simpson, 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 Ralph Simpson, on
the 24th day of September, 2010.. That by reason of and upon the death of Ralph
Simpson, title in the above described real property vested in Ann Simpson.
Affiant avers and certifies that Ralph Simpson is the identical party named with
Ann Simpson 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.
2011.
Subscribed and sworn to before me, a notary public in and for said County and
State, by Ann Simpson, this t day of A--)n 2011.
2z
00015i1
Ann Simpson
RECEIVED 5/2/2011 at 11:49 AM
RECEIVING 959126
BOOK: 766 PAGE: 151
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
CERTIFICATIO ITAL RECORD
7
DECEDENT INFORMATION
Date of Death: September 24, 2010
St. George
81
Kelchum, Oklahoma
Yes
Anna H Simpson
Aeronautical Missiles
Washington, Utah
Myrtle Elma Wynn
Kolob Care and Rehabilitation
City of Death:
Place of Birth:
Armed Services:
Spouse's Name:
Industry/Business:
Residence:'
Mother's Name:
Facility or Address:
STATE OF UTAH
'vWliVitiVvV,VIVP 111W..al YI.. i!-.WA1I' 1 ..I1..,+VirY;,.. \M1...Y..,rYfi'; Viv'eVivVeW
CERTIFICATE OF DEATH
State File Number: 2010011098
Ralph Leavern Simpson
Time of Death:
County of Death:
Date of Birth:
Sex:
Marital Status:
Usual Occupation:
Education:
Father's Name:
Facility Type:
INFORMANT INFORMATION
Name: Sharon K m
e rC;ieyer. Relationship:
Mailing Address: 254 East 650 South, lvins,' Utah 84738
DISPOSITION INFORMATION
Method of Disposition: Cremation"
Place of Disposition: Metcalft.Mortuary Crematory; St George,." Utah
Date of Disposition: September 29, 2010
FUNERAL HOME INFORMATION
Funeral Home: i PineView Mortuary
Address: `566 North Mali Drive; `St George, "Utah 847.90
Funeral Director: Jon R' Wallis
MEDICAL CERTIFICATION
Medical Professional C. Kerry Stratford MD';
Date Issued: September 30, 2010
George Clinic, St George, "J
1111111111i111111 11
08:35
Washington
February 5, 1929
Male
Married
Aircraft Mechanic,
9th Through 12th Grade
George E Simpson
Nursing Home/Assisted Living
Niece
ah 84790
CAUSE OF DEATH
Natural causes
Due to (or as a consequence of); weakness
Due to (or as a consequence of)f Clostnum Difficile Cerebrovascular, Accident'
Due to (or as a consequehce Tongue cancer;
Other significant conditions HTN,' Asthma, DM
Tobacco Use: Unknown`
Medical Examiner Contacted; Yes Autopsy Performed: No Manner of Death: Natural
000152
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 the Utah State Seal, over the words "State of Utah
This document displays the date, seal and signature of the State Registrar of Vital Statistics.
e 7444
Barry E. Nangle O "6 2 7 0 3 5 4*
State Registrar
UTAH DEPARTMENT OF HEALTH
Office of Vital Records Statistics
Salt Lake City Utah
We/P. qU 4 111
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