HomeMy WebLinkAbout959731AFFIDAVIT OF SURVIVORSHIP
I, NAOMI G. JOHNSON, being duly sworn under oath, state as follows: 000236
1. That I, Naomi G. Johnson, the surviving spouse of Farrell D. Johnson, hereby
certify that Farrell D. Johnson died on February 14, 2009. Attached hereto is an original copy of
the Certificate of Death issued for Farrell D. Johnson.
2. That Farrell D. Johnson had tenancy by the entireties with me in land in Lincoln
County, Wyoming, more particularly described as follows:
See the attached Warranty Deed creating the tenancy by the entireties that was
recorded in the Lincoln County, Wyoming, land records in Book 74 PR at Page 75 on
May 3, 1966 as Instrument No. 394719.
3. That pursuant to Wyoming Statutes 2 -9 -102, I certify that the tenancy of Farrell
D. Johnson has been terminated by his death, and that title to the above referenced land is now in
the name of Naomi G. Johnson, a single woman.
DATED this 16th day of June, 2011.
RECEIVED 6/20/2011 at 10:32 AM
RECEIVING 959731
STATE OF UTAH BOOK: 768 PAGE: 236
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
SS.
COUNTY OF SALT LAKE)
SUBSCRIBED AND SWORN TO before me by NAOMI G. JOHNSON this 16th day
of June, 2011.
WITNESS my hand and official seal.
M. KEVIN VOYLES NOTARY PUBLIC
COUNTY OF STATE OF "j�
LINCOLN °•1 WYOMING
MY COMMISSION EXPIRES JULY 16, 2019
My Commission expires: 07
1
NAOMI G. JOHNSON
CERTIFICATION OF VITAL RECORD
DECEDENT• LEGAL NAME
FARRELL.D. JOHNSON
SEX SOCIAL SECURITY NUMBER AGE. DATEOFBIRTH
MALE 73 YEARS DECEMBER 16, 1935
BIRTHPLACE PLACE OF RESIDENCE
A WYOMING AUBURN, WYOMING
'�IIIilM AftAL STATU$ AT 1 ME OF Di:AT9 NAMF BURNING SPOUSE (1! oije, maiden name) WAS DECEDENT EVER IN
II 1 11 US. ARMED FORCES?
M A R R;'YIED NAOMI GAYS TAYLOR YES
FATHER •.NAME NAOMI
BIRTHPLACE
ROLLIN JOHNSON WYOMING
MOTHER• MAIDEN NAME BIRTHPLACE
LAVON DAMS IDAHO
METHOD OF DISPOSITION FUNERAL SERVICE LICENSEE
REMOVAL FROM STATE MICHAEL D. BELL
NAME AND ADDRESS OF FUNERAL FACILITY
SCHWAB MORTUARY, AFTON, WYOMING
DATE OF DEATH TIME OF DEATH CITY ,TOWN OR LOCATION OF DEATH COUNTY OF DEATH
FEB. 14, 2009 4:05 P.M, BOISE, IDAHO ADA
CAUSE OF DEATH (Underlying cause last) Approximate Interval Between
a Onset and Death
CHRONIC DEMYELINATING'I, POLY;NEUROPATHY
DUE TO (or as a consequence of)!.
b SEVERE HYPDXEMIA
DUE TO (or as a consequence of):
irO
DUE� (or:as bonsequencelo)
OTHER SIGNIFICANT CONDITIONS` CONTRIBUTING` TO DEATH but not resulting in the underlying cause given above WAS AN AUTOPSY
PERFORMED?
NONE STATED NO
MANNER OF DEATH NAME OF CERTIFIER TITLE
NATURAL STEVEN D. FULLER, D.O. PHYSICIAN
CORONER SUBSEQUENT CERTIFICATION IF NECESSARY
LOCATION WHERE IN)UI Y OCCURRED
DESCRIPTION OF HOW INJURY OCCURRED
a �aa umg q u11
t ip( FEBRUARY 24, 2009 .2G�y�
1 G Q1 B DATE ISSUED
t
I A st This copy is not valid unless prepared on engraved border JANE S SMITH
q� y displaying state seal an signature. of the Registrar STATE REGISTRAR
This is a true and correct reproduction of the document officially registered and placed
on file with the IDAHd BUREAU OF VITAL RECORDS AND HEALTH STATISTICS.
DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
TIME OF INJURY:
STATE OF IDAHO
INJURY AT
WORK?
1oTQSTA"!1C R
i
II
WARRANTY
grantor_ of
of Nevada
in hand paid, receipt whereof is hereby acknowledged, CONVEY AND WARRANT T0_
Farrell D. Johnson and Naomi G. Johnson
husband_and_wi£e,__ bat the- entixeties
gran_ tee5__, of Lincoln County and State of
Lincoln li
the following described real estate, situate in _County and State
I'
of Wyoming, hereby releasing and waiving all
to-wit:
a vmamxuua,w
WITNESS our hand S this day
7
Six Thousand and nol00
IWn,mnn„mna..,n u,nml. iumWPMI
VIVIAN I. GUMNS
°u'NI c State of Nevada
Ormsuy County
My Commission Expires Nov. 1, 1967
Mm,nwwopx,wrpwY,l Mn, nnN, Nnm nnun,mn.,,.,,*
RECORDED.
WARRANTY DEED No. 94 19
Garland Toland and Grace Toland, husband and wife
,for and in consideration of
My commission expires on the___. J day of__
rights under and by virtue of the homestead
Wyoming
Commencing at the Northwest Corner of Lot No. 2 in Block
No. 9 of the Town of Auburn, Wyoming, and running thence
East 20. rods, thence South 16 rods, thence West 20 rods,
thence North 16 rods to the place of beginning, containing
2 acres, more or less.
19 66
THE STATE OF Ate; d�
County of___ .�3[YY�"
On this____a3 day of 19_ 66 before me personally appeared
Garland Toland and Grace Toland, husband and wife
to me known to be the person 6 described in and who executed the foregoing instrument, and acknowledged that__ tb t__
i
t her a kJ�.Q.e. i yiu n.Z`°ry 4
executed the same as free nct and deed if Iv
NOTARY PUBLIC
County, and State
DOLLARS
exemption laws of the State,
4.4 it ,A.D.,191Z.
MERER.
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