HomeMy WebLinkAbout959755RECEIVED 6/21/2011 at 2:43 PM
RECEIVING 959755
BOOK: 768 PAGE: 297
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
ssANE
tib If.
4 OF Wy `\y
f iniii11110
000297
We, David Alan Hunzie and Patricia E. Hunzie, being of lawful age and duly sworn
according to law, upon our oath, depose and state:
That under the date of May 3, 1976, for valuable consideration, Uinta Improvement Co.,
by deed of that date, which deed was duly filed of record in the Office of the Lincoln County Clerk,
on September 16, 1976, in Book 130PR, Page 327, conveyed to David Alan Hunzie, a single man,
and Harry S. Hunzie and Patricia E. Hunzie, husband and wife, all as joint tenants with rights of
survivorship, the following described land, in the County of Lincoln, State of Wyoming, to -wit:
Lot Seventeen (17) of Block Four (4) Lincoln Heights 3rd Subdivision to the Town of Kemmerer,
Lincoln County, Wyoming
That by reason of said conveyance aforesaid, the said David Alan Hunzie, a single man,
and Harry S. Hunzie and Patricia E. Hunzie, 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 Harry S. Hunzie, on the 21st day of November, 2005. That by reason of and
upon the death of Harry S. Hunzie, title in the above described real property vested in David Alan
Hunzie and Patricia E. Hunzie
Affiants aver and certify that Harry S. Hunzie, is the identical party named with David
Alan Hunzie and Patricia E. Hunzie in the aforementioned deed, whose death terminated his
interest, title and estate in said real property; and Affiants attach hereto, and make 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 2E5 day of JLLE 2011.
State of LL fC_l (j.ye
ss.
County of LL ry
WITNESS my hand and official seal.
Affidavit of Survivorship
Subscribed and sworn to before me, a notary public in and for said County and State, by
David Alan Hunzie and Patricia E. Hunzie, this a0 day of o,14 e 2011.
This Document i9 being recorded by
Rocky Mountain_ Title Ifl uMnce Agency
of Lin Coln County as a COURTESY only
David an Hunzie
6 .4/r4gr:c.*:--> e
Patricia E. unzie
Notary Public
1
To Be CompletedNerified By:
FUNERAL DIRECTOR
1. DECEDENTS LEGAL NAME (Include AKA's If any) (First, Middle, 1001)
Harry Sylvester Hunzie
2 SEX
Male
3. DATE OF DEATH (MO /Day/Y1) (Spell Month)
November 21, 2005
4. SOCIAL. SECURITY NUMBER.'
5a.i1GE Lag( Birthday
(Veers)
5th UNDER 1 YEAR
550 UNDER
1 DAY
4. DATE OF BIRTH (Mo/Day/Yr)
May 27, 1923
Months
Days
Hod
Mule
74. PLACE OF DEATH (Check on one)
IF DEATH OCCURRED IN AHOSPITAL
0 lnpai(enl 0 E 004,8anl 0 DOA':
IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL ,,11
0 Hospice Facllby 0 Nursing Horne/ Long Ton*0arc Faculty ?.1 Decedent's Kano 0 0(0er (Specify)
10. FACILITY NAME 01 not Institution. gle street anti somber)
1013 Sage Avenue
Residence 1
7. CITY, TOWN. OR LOCATION, OF DEATH
Kemmerer
70. COUNTYOF DEATH
Lincoln
L
9. BIRTHPLACE (City and stale or foreign country)
Superior, Wyoming''
g MARITAL STATUS AT TIME OF DEATH
XMarded OM med,bldsapareled' 0.WSdowetl
00wa,ed rl NemrMarried 0Unknown
10 SURVIVING SPOUSE (If wile, give name prior to first marriage)
Patr Ellen Kolata
1 1 EVER IN U.S.
ARMED FORCES?
n YES DINO
12a. RESIDENCE -STATE
Wyoming
}2b COUNTY:'.
Lincoln
120 CITY. TOWN OR LOCATION
Kemmerer
124. STREET AND NUMBER
1013 Sage Ave
12e. ZIP CODE
83101
12f. INSIDE CITY LIMITS?
p( YES 7 N
13. FATHER'S NAME (First, MM010, cast)
John Hunzie
14. MOTHER'S NAME'PRIOR TO F 0157/MARRIAGE (First, MIdd8. est)
Mary Dubinsky
158. INFORMANT'S NAME
Patricia Ellen Hunzie
15b. RELATIONSHIP TO DECEDENT
Wife
15c. MAILING ADDRESS(Siraeland Number. 5119. S1ale.Z1p Code)
.1013 Sage Ave Kemmerer, Wyoming 83101
18, METHOD OFDISPOSITION'.
8una1 0 Don0gen El Removal from Wyoming
n Cremation O Entombment other
172: :RLACE OF DISP0510(ON (Name of
cemetery or crematory)
UFD Cremation Center
17b. LOCATION- CITY OR TOWN AND STATE
South Jordan, Utah
8a.SIG o h1 ALSERVICELIC E
yy �y55
Z
1Bt, LICENSE NO,..
464
i 9a NAME OF FACILITY
Crandall Funeral Home
1S b. ADDRESS OF FACILITY
91,5 Pine, Ave. Kemmerer," WY.
To Be Completed By:
CERTIFIER
20. ACTUAL OR PRESUMED TIME OF D H
10:45Actual
21 DATE PRONOUNCED DEAD (Mo10ay/E)
November 21, 2005
22.718E PRONOUNCED DEAD
10:45
23. WAS CORONER C049740 ED7
n YES 01 NO
CAUSE OF DEATH
24. PPR) I Enla.11c chsm 07011,. diseases diseases i ie or complications L,aldi.ecllyersadIn, death DO NOT enle1`ermlllal evutns such as taid,ec
as4l/el0ry wrest, or eantncaler fibrillation h 1 001031110 ecology DO NOT ABBREVIATE Enler only one cause na Me Ada additional lines
ry.
IMMEDIATE CAUSE (6043 diseas or u i CyN 0 9 7 e Cr' r j S
a.aarnximale i nterval
Ousel ur dawn
K?, 5
condition resulting In death) DUE TO (OT 00 a conseoue /ce,OT)
Sequonitioy let conditons,.Ptly:
1,8510510 the cause lited online a
Enlarlhe UNDERLYING CAUSE
(dls0ase or Injury that In9leted DUE TO (or as a consequence 01); I
events nsuflmg in death) LAST
DUE TO (ores a w03e4uenc. of),'., I
PART 11. Enter blher algti)ficanl conditions contdlatbg l 0. death WI not resua lv1 b the UMerlykl9 caught 01 In Pan l
25. WA5 AN AUTOPSY..
PERFORMED?
n 111 NO
20. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH?
n YES 0 NO
27, DID TOBACCO USE CONTRIBUTE TO DEATH?
IVES 0 07... ❑PROBABLY 0 UNKNOWN:
28. IF FEMALE:AGED 10.54
0 Not pregnant within past year O Nol pregnant, Sul pregnant 43 days 101 year before death
n Pregnant al limool death n Unknown if pregnant N91011110 pas( year
El Not pregnant. but pregnant w0hin 42 days of death
29. MANNEROF DEATH'
CY Natural 0 HdnIOde
11 Accident n Pending Invesllgallonn
n Suicide n Could not b0 determined
30. DATE OF INJURY(Mo/Day/Yr)
31. TIM OF INJURY
2 PLACEOF INJURY,:(Dec0denlehorn. mnslrucil o site fomsl, olc.)
33. INJURY ATWORK5
nYES 0 N
34. LOCATION OF INJURY (Street and number. Cay or To Stole)
35 IF TRANSPORTATION ACCIDENT, SPECIFY
n Doverl Operator 0 Pedestnan
n Passenger n Other (Spacl(y)
3G'OESC9IBE HOW INJ)IRY OCCURRED, AND IF TRANSPORTATION INJURY THE TYPE(4) OF VEHICLE($) eiv01550 (A'al nob le pickup, molorcyGO. ATV, blcyOIe, etc:)
37a. CERTIFIER (Check only one)
2( PHYSICIAN- To the best of my. •wl. dge occuned at lit dale and place, and due to the causes) and manner slated. r
CORONER -On4he base. of a ini a o1 :sbge 41/3 0)1710504091/1 ociurted al We lime, dale and placa, and due.to the cause(s) and ,nanner slated
Slgnatllmof Certifier
370. DATE CERTIFIED (MO -y n
November..22, 2005
370 NAME, TITLE AND ADDRESS OF CERTIFIER (Type or prim)
Cris Krell, M.D.
7 1. Y emme,. Onyx„ KrerWY 83101''.
38a. REGISTRAR'S 5 TUR
.e jpe„.
381. DATE RECEIVED BY REGISTRAR (MO/Day /Yr)
November 24, 2005
t
STATE OF WYOMING
LOCAL FILE NUMBER 1036
290823
This is a true certification of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.
DATE ISSUED:
it
a
CERTIFICATIO ITAL RECORD
DEC 5 2005
STATE OF WYOMING
DEPARTMENT OP :HEALTH
CERTIFICATE OF DEATH
This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and siggature of the Deputy State Registrar.
STATE FILE NUMBER
Lucinda McCaffrey
Deputy State Regitrar
gagty., ag, a5
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