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Home My WebLink About96034063403 Hickman 1 jand'tleCo SI NCE 1904 6 ^r I, M. HOPE DAVIS, being first duly sworn on oath, depose and say: LEGAL DESCRIPTION Tax Roll No. 36192610025000 Dated this '7 -2 day of July 2011 A.D. AFFIDAVIT RECEIVED 8/2/2011 at 4:38 PM RECEIVING 960340 BOOK: 770 PAGE: 419 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY 000419 That I am a citizen of the United States of America over the age of 21 years, and a resident of NEW YORK. That I was well and personally acquainted with THOMAS E. DAVIS t,____T_tst +l e in that certain Warranty Deed dated 5/20/1996 and recorded 5/29/1996 in Book 383 PR, at Page 819, as Filing No. 820483, in the office of the Recorder of LINCOLN County, WYOMING. That I know of my own knowledge that THOMAS E. DAVIS in the said deed and THOMAS E. DAVIS SR. mentioned in the attached Certified Copy of Certificate of Death was one and the same person. This affidavit is intended to terminate the tenants by entireties vesting on the above referenced Warranty Deed of said THOMAS E. DAVIS in the following described property: That part of the NE'/4NE /4 of Section 26, Township 36 North, Range 119 West, Lincoln County, Wyoming, being part of that tract of record in the Office of the Clerk of Lincoln County in Book 383 of Photostatic Records on Page 819, described as follows: BEGINNING at a spike on the East line of said NE1/4NE1/4, North 00 °04'54" West, 250.92 feet, from the Southeast corner thereof; Thence North 89 °32'41" West, 1,315.17 feet, to a point on the West line of said NEY4NE1/4; Thence North 00 °07'24" West, 249.73 feet, along the West line of said NE' /4NE' /4, to the Southwest point of that tract of record in said Office in Book 538 of Photostatic Records on Page 252; Thence South 89 °26'00" East, 1,315.38 feet, along the South line of said tract in Book 538, to the Southeast spike thereof, on the East line of said NE' /4NE' /4; Thence South 00 °04'54" East, 247.17 feet, along said East line, to the Spike of Beginning. DF 63403 INDIVIDUAL ACKNOWLEDGMENT STATE OF NEW YORK SS County of VSZ-�.)3... A On the 'day of July A.D. 2011 personally appeared before me M. HOPE DAVIS the signer(s) of the within instrument, who duly acknowledged to me that he /she /they executed the same. Commission expires: Residing in: 000420 Not Public 'MOREL A. MEAD Notary Public, State of New York No. 4919868 Residing in Rensselaer County Commission Expires Feb. 8, -1 ...Z- DF 4kPLACE OF DEATH:__HOSPITAL HOSPITAL NURSING:T.? :RBIVATE (Check onek., 'ER= TounKIINT INRATIENTM0ME RESIDENCE MIDDLE LAST E. Davis 38. DATE OF DEATH: 38. HOUR: MONTH DAY YEAR I 0_4 15 I 2 0 1 1_ 0_0:1 3 4:48. IF FACILITY, DATEADM DAY ff.RESIDENCE NCHS 4C 42. NAME OF FACILITVIf nagfildy, give address) St. Mary's Hospital ERTAGATRINt TEhetIesnT my kniAVIedgeia at the time date and place and er'sNamf e License No.: 7, wato -7A SI 30 ti 4F. MEDICAL RECORD NO. M000277602 5. DATE OF BIRTH:- MONTH DAY 01 I 04 I 8. SERVED IN U.S. ARMED FORCES? (Specity yeits NO YES Es 3CiTj 1954 1 956 11. DECEDENT'S EDUCATION: Check the box !bat bestdescribes the highest degree or level of school completed at Me time of death. 105 818 grade Y20 918-1218 grade; no diplopia 13 0rachool graduate or GED 4 0 Some college cmdit, but no de :5 0 Associates dALe 61_JlacRdlCrs degree 7 0 Masters degree 0octoraUss8n 12. SOCIAL SECURITY NUMBER: 15A. USUAL 0CCUPATION:f(06:7f0teriter:retlFcl Superid 16A. RESIDENCE: (State or Coun(x if not USA) New York 168 STREET AND NUMBER OF RESIDENCE' 222 Verbeck _Avenue 17. NAME OF FATHER: 198. NAME OF INFORMANT: 'Maud Hqpe; YEAR FIRST Thomas 22A. NAME OF FUNERAL DIRECTOR: A ha J. Chase •26A. Attending physician attended deceasa (A) 1 9 34= -JTDEDEDENIOFRISOLIIC ORIGIN? Oeckthefipsp.Wat fiktdiAlibe the deceders Spanisttklispl e121 Von Mexidan Americ30jChibo Yes, Puerto Rican 80 Yes, Cuban 80 Yes, Other Spanish/Hispanic/Latino (Specity) PART I. IMMEDIATE-CAUSEn DUE TO OR AS A CONSEQUENCE OF: =DUE TO OR AS A CONSEQUENCE OF: Month CONFIDENTIAL DEPARTMENT OF HEALTH EFIcATEQ H 487RGALITYTheck one and specify) N I CITY VILLAGE TOW 1 vi 0 0 Troy :k4G.,WAS DECEDENT TRANSFERRILLERMNOTHER INSTITUTION? (If yes, ,specikinetitution name, city or town, counlyAnd4tgtff):. ,L YEAR I 6C. IRUNDER 1 7/k. CITY AND STATEKIFRIRTHRIfit_FUSA-ountly and YEARS I ENTER: 1 ENTER: 1 Region/Province) I months days I hours minutes 7 7 yrs I Scranton -I 13. MARITAL STATUS: NEVER MARRIED MARRIED WIDOWED DIVORCED SEPARATED 0i >fit 2 03 04 05 68:Coun ti or Region/Province i it not A: enssela.er MI E. I 158. KIND OF BUSINESS OR INDUSTRY: I I Education LAST Davis, Sr. 238. DAT FILED: MONTH DAY THRU 33_COMPLETED BY CERTIFYING PHYSICIAN OR 1W46‘ liValitigft_ e Inn hysiciaiii A4D i gep, 11 „Ektgirrer; 258. If coroner isinot a physi an Physitlar&nerie titLef 25C. If certifier is not attendihg,pPysiclan, enter Attencling name :8, title: License No:: Year Month Dayiai. Year 30. DEATH WAS CAUSED BY: (ENTERSINLY-ONE CAUSE PER LINE FOR (A)1(6)8EiM) HOSPKE FACILITY :(C) PART II. OTHERSIGNIEIGANT CONDITMODONTRIBUTINBTO DEATRIBEITiNOMELATEOTEFRAU IN PART a _A 31A. IF INJURY, DATE IT 1 HOUR: 1 318.151282 LOCALITY: (City or town and counNland state) MONTH DAY YEAR 1 I I I 1 M i I 318. IF TRANSPORTATION INJURY, SPECIFY: 32. WAS DECEDENT 1 0 Driver/Operator 20 Passerig Pedestrian HOSIVAbIZMIN i i s irfoirit dirfiCio 09421 I 19B. MAILING ADDRESS: (include zip code) ct 222 Verbeck Avenue, NY 121=5 1= 5 0 DONATION :1110B. PLACE OF BURIAL„CREMATIOWREMOVALOR OTHER YEAR I 2011 iElmwood- 31 20k 4 Ele1.1RIA1-- AL 4 O 6 ID ENTOMBMElici I 04 I 18 318 21A. 319 Park Avenue NAME AND ADDRESS OF FUNERAL HOME. Chase-Smith Family Funeral HOITle_S Mechanicville, NY 12118 228. SIG TURE OF FU RAL DIRECTOR: I r YEAR 162. LOCALITY: (Check one and specify) mr. IF CITY OR VILLAGE, IS RESIDENCE CITY 'VILLAGE TOWN WITHIN CITY OR VILLAGE LIMITS? 0 0 Schaghticoke OYES ONO IF NO, SPECIFY TOWN: 18. MAIDEN NAME:: OF MOTHEFK 5 01 DECEDENT'S BACE i Check one oi what the decedenCcoosia eltprhefaelf In be: Whiie/Cau6siaZ 8 n Black-or African Americali80Mian indian D ri 7Clilfiese E 0 Filipino-: P 0 Japanese W10 Kcife H 0 Vietnamese J 0 Native Hawaiian K 0 Guamanian or Chamorro MO Samoan N CI American Indian or Alaska Nativ.OpagcifK) Other-Astars iliNg o0 Other Pacific Islander (specify) asA I 14. SURVIVING SPOUSE: Enter name if married or separated. It surviving spouse's wife, enter maiden name. Maud Hope Wilson_ 1 5CNAMg Wei g A AL OR REM e causes stated. natur 27. MANNER KW a AINOETERMTNED7 PENDING NATURAL CMS f HOMICIDE SUICID CIRCUMSTANCES INVESTIGATON rw, 02 03 01 SEE INSTRUCTION SHEET FOR COMPLETING CAUSE OF DEATH PA 16E. ZIP CODE: I 12154 ORONER'S PHYS FIRST Anne PERMIT I STATE FILE NUMBE 4E7COUNTY OF DEATH: 05 2-01 1 I Rensselaer 713T,IF-A5E0NDERd YEAR;NAME OF HOSPITAL 'BIRTH: Ls AflPN- MI L. LAST Healy I 20C. LOCATION: (Cityor tOtvaid state) Schaghtitoke, NY EDICAL-EXAMINER 1 218. REGISTRATION NUMBER: I 00491 I 220. REGISTRATION NUMBER: 00629 1 24B. DATE ISSUED: MON DAY YEAR a to Month Day Year r I 268. Deceased lasLseenIllvs byfattendintitySirian:ii 4, enth Day 20VA61DASEREFERRED T0 11 ,T7=7 OR MEDICAL EXAMINER? 12 0 NO 1 0 YES e."04-r 1 31C. DESCRIBE HOW INJURY OCCURRED: 33A. IF FEMALE: o0 Not presnantwithin Iasi yea,L 11=1 Pregnant al iime Year 26C. P f Oun au nced Month Day seat ON Time 29VAUTOPSY? 2913RIFLYESXERLEINDINGS USED TO DETERMINE NO YES REFUSEDtCAUSUELDEATHr 0 01 02 E 0080 1 DYES abut pregnant within 42 days of death CONFIDENTIAL APPROXIMATE INTERVAL BETWEEN ONSET AND DEATH Ion cODsECoNTRieUTEITo DEATH? FE -N041._04ES n PROBABLY 3 0UNKNOVVN 1 3187 OF .1 31E. INJURY AT WORK? I 1 ILKI, YES I 1 mu 0 LI 1 .33B. DATE OF DELIVERY: MONTH DAY YEAR I 1: EXHIBIT "A" 000422 That part of the NE'/4NE1/4 of Section 26, Township 36 North, Range 119 West, Lincoln County, Wyoming, being part of that tract of record in the Office of the Clerk of Lincoln County in Book 383 of Photostatic Records on Page 819, described as follows: BEGINNING at a spike on the East line of said NE1/4NE1/4, North 00 °04'54" West, 250.92 feet, from the Southeast corner thereof; Thence North 89 °32'41" West, 1,315.17 feet, to a point on the West line of said NE'/4NE' /4; Thence North 00 °07'24" West, 249.73 feet, along the West line of said NE' /4NE' /4, to the Southwest point of that tract of record in said Office in Book 538 of Photostatic Records on Page 252; Thence South 89 °26'00" East, 1,315.38 feet, along the South line of said tract in Book 538, to the Southeast spike thereof, on the East line of said NE' /4NE1/4; Thence South 00 °04'54" East, 247.17 feet, along said East line, to the Spike of Beginning. Land Title Company Underwriter Stewart Title Guaranty Company