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Home My WebLink About960687Fits document is being recorded by and Escrow of Wyoming, LLC as a courtesy only ss. AFFIDAVIT TERMINATING ESTATE 0006111 being of IawfuI age and first duly sworn according to law, up my oath, depose and state: Dated JILL H. LARSON NOTARY PUBLIC County of ��s�" State of Lincoln Wyoming My Commission Expires June 20, 2015 1. That 1 am of adult age, a resident of Affiant herein. 2. That by virtue of the conveyance which is recorded in the office of the County Clerk for Lincoln County, Wyoming, located at Kemmerer, Wyoming in Book d Q PR on page O is recorded a Warranty Deed. The Warranty Deed dated the 0/ 7 day of c520 o le conveys unto sband and Wife as Tenants by the Entireties ith full rights If survivorship the following described property, to -wit: and the See attached Exhibit "A" 3. That said (,1yAA 'ZU pima• on the 9 day of 007, died and a copy of the original J� certificate of death, certified to as true an correct by public authority in which the original of said certificate is a matter of record, is attached hereto as Exhibit "B 4. That by reason of death of said e..,6n,& i by reason of 2 -9 -102 W.S. (1980), the decedents interest an ti tle in said conveyance has terminated and title to the real property conve ed thereby has vested absolutely in e V L AG`°''''' ('2.t.LA continuously since the death of the said decedent. FURTHER AFFIANT SAYETH NOT. The foregoing c9 cD AO/ this day of Witness my hand and official seal. instrument was subscribed an d sworn to me by ri a// ut My Commission Expires: fo 0 0 /.5 Notary Public RECEIVED 8/25/2011 at 10:05 AM RECEIVING 960687 BOOK: 771 PAGE: 611 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY EXHIBIT "A" 000612 Commencing as a point which its 470 feet North of the Southwest Corner of the Southeast Quarter of the Southeast Quarter of Section 26, T33N R119W of the 6th P.M., Lincoln County, Wyoming and running thence N90 00'W, 260 feet; thence N0 00' W260 feet; thence N 90 00' E, 260 feet; thence S 0 00'E, 260 Feet to the point of the beginning CERTIFICATI ITAL RECORD DECEDENT TYPE OR PRINT IN PERMANENT SLACK INK 00 NOT USE FELT TIP PEN FOR INSTRUCTIONS SEE HANDBOOKS DISPOSITION PLACE OF DEATH DATE OF DEATH CAUSE OF DEATH ITEP,IS 32 -38 TO BE USED FOR EXTERNAL CAUSES ONLY (CORONER) _71a111AL711 IF DEATH WAS DUE 80 OTHER THAN NATURAL CAUSES, 1HE CORONER MYSI COMPLETE 460 SIGN THE CERTIFICATE DATE FILED BY STATE REGISTRAR: State of Idaho CERTIFICATE OF DEATH STATE FILE NO °Mxs'e .Swxu eF U6so �s [xcN e =g317u.:WEr==.:37=UOr Local Reg. No. (4`� L 7 1. DECEDENT'S LEGAL NAME (Include AKA's if any) (Firs), Middle, Lasl, Suffix) 2. SEX 3. SOCIAL SECURITY NUMBER Clint W. Johnson 'O 4a. AGE -Last Birthday 4b. UNDER 1 YEAR O M onths i Days 64 (Years) 70. RESIDENCE STATE OR FOREIGN COUNTRY 7b. COUNTY Idaho 7d. STREET AND NUMBER 2860 Highway 238 2 c 10. EVER IN U.S. C ARMED FORCES? Yes 8. MARITAL STATUS AT TIME OF DEATH 12 Married 0 Marled, but separated 0 Widowed Divorced ❑(Never manted Unknown Gloria Ella Luthi 11a. FATHER'S NAME (First, Middle, Last. Suffix) 11b. BIRTHPLACE (51ate, Territory, or Foreign Country) Ervon Charles Johnson Wyomi 12a. MOTHER'S MAIDEN NAME (First,. Middle, Lest, Suffix) 12h. BIRTHPLACE (Slate, Territory, or Foreign Country) R No Eva Fdss Walton Wyoming. 130. INFORMANT'S NAME (Type or print) 13b. RELATIONSHIP TO DECEDENT 13c. MAILING ADDRESS (Street and Number. City, Stale. Zip Code) 2860 Highway 238 Gloria Johnson wife Auburn, Wyomin_g 83111 *14. METHOD OF DISPOSITION 15. PLACE OF DISPOSITION (Name and address of cemetery, 16. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY I@ Burial Cremation crematory, other place) Schwab Mortuary Donation Entombment Auburn Cemetery 44 East 4th Avenue El Removal from Idaho Au bur n Other( Auburn, Wyoming y) yomin Afton, Wyoming 83110 17a. S NATURE OF FUNERAL RVICE LICENSEE,OR PERSON ACTING AS SUCH t7b. LICENSE NUMBER (01 licensee) M 676 PLACE OF DEATH 19 -22 19e. IF DEATH OCCURRED IN A HOSPITAL: 19b. IF DEATH OCCURRED SOMEWHERE OT THAN A HOSPITAL: ,M Inpatient oU ER/Outpatient 30 0 0 4 1 Hospice facility s[I Nursing home/Long term care laciliy a i De0edenl's home i J Other (Specify) 21. CITY, TOWN, OR LOCATION OF DEATH; AND ZIP CODE 20. FACILITY NAME (II not facility. give' street and number) Eastern Idaho Regional Medical Center Idaho Falls 83404 23. DATE OF DEATH (Mo/Day/Yr) (Spell month) 24. TIME OF DEATH 25. DATE PRONOUNCED DEAD (Mo /Day/Yr) (Spell month) September PART 1. Enter the arrest, respiratory arrest. o 394. NAME, ADDRESS, Kenneth E. 40a. C RONER'S SUBSE' physician assistant, I have reviewed and if nec X 410. R A/ R'S SI O NA L 9, 2007 0055 (24hr) September 9, 2007 0055 (24hr) 27 CAUSE OF DEATH chain 01 q venl6 diseases, injuries. or complications --Mal directly caused lhe death. DO. NOT enter terminal events such as cardiac Appr°ximale. Interval: r ,4entdcslar f rillalion hour showin• me etiology. 00 90 A: BREVIATE. Enter only, one cause on a line: Onset (d Death i IMMEDIATE CAUSE (Final f.i0 Elsease or condition a resulting in death) Sequentially list conditions. b. It any, leading t0 the cause eUE T listed on line a. Enter the UNDERLYING CAUSE C. LAST (disease or injury 506 Ihat initialed Ihe events resulting in death) d. 29: DID TOBACCO USE CONTRIBUTE TO DEATH? 0 Yes Probably 4Io C7 Unknown D 32. DATE OF INJURY (MO/Day/Yr) E (Spell month) 36. LOCATION OF INJURY: Stale TRANSPORTATION 38a. WAS DECEDENT: INJURY ONLY 0P eslrian 39a. CERTIFIER (Check only ne, based 1C1 PHYSICIAN 0 PH Y To Ihe best of my knowle •ge, d CORONER On the basis of OSOnrin and manner staled. Signature and Title of Ca f ter► IDAHO DEPARTMENT OF HEALTH AND WELFARE BUREAU OF HEALTH POLICY AND VITAL .STATISTICS 30. IF, FEMALE (Aged 10 -54): Nolpregnant within.p001 year 0 Pregnanl al lime of death [I Nol pregnant, but pregnant within 42 days of death 33. TIME OF INJURY 0 ZIP CODE OF Dover/ er (Specify) facial capacity IAN ASSISTANT h. occurred al the ti and/or investigation,1 UENT advance• sa TIRE Is certificate) le; and pl icon, death (Type or print) 200 S. C SARV:. The !One rse. an ADVANCED PR e, and due to the tarred at the SIGN RE IF NEC= rack! profession ended Ihe medical sec 4c. UNDER 1 DAY 5. DATE OF BIRTH (MO/Day/Y Hours Minutes June 9, 1943 Lincoln. (24hr) or PO55enge 'DATE ISSUE This copy not valid unless prepared on engraved border displaying state seal and signature of the Registrar. PSNCO (Rev) 11/06 1 Not pregnant, but pregnant 43 days l0 1 year belore death 1 Unknown it pregnant within the past year City/Town or County TICE. PROFESSIONAL NURSE cause(s)/manner staled. e, dale, a -nning Wa Ida •oar's signalure in this (ten supersedes coroner becomes the ce00ter of record. Po g 4 1'- but not resulting in the underlying cause given in Part lI pee. WASAN AUTOPSY 286. WE E AUTOPSY. FINDINGS I PERFORMED? AVAILABLE TO COMPLETE I THE CAUSE OF DEATH? I1 Ves I�.I No 3 MANNER DEATH tealural Homicide I Accidenl Pending Investigation tiTi Suicide _i Could nol be determined 34. PLACE OF INJURY (Decedent' home, farm, street, construction site. nursing home. restaurant, forest, etc.) Street and Number or Location Apanmenl Number 37. DESCRIBE HOW INJURY OCCURRED. IF TRANSPORTATION INJURY, STATE THE TYPE(S) OF VEHICLE(5) INVOLVED (Automobile, pickup, motorcycle, ATV, bicycle, etc.) SPECIFY WHICH VEHICLE DECEDENT OCCUPIED, it applicable This is a true and correct reproduction of the document officially registered and placed on file with the IDAHO BUREAU OF HEALTH POLICY AND VITAL STATISTICS. Male 6. BIRTHPLACE (City and S ale, Territory, or Foreign Country) Afton, Wyoming 7c. CITY OR TOWN Auburn 7e.' APT. NO. 71. ZIP CODE j7g. INSIDE CITY 83111 LIMITS? (]-`'es (No 9. SURVIVING SPOUSE'S NAME (II wile, give maiden name MM o Falls, Idaho 83404 18. WAS CORONER CONTACTED DUE TO CAUSE OF DEATH? 0; Yes X1 No Zip Code W WHAT SAFETY DEVICE(S) DID DECEDENT USE/EMPLOY? :al Belt Child saley,seal Helmet Air bag I! None 1 Unknown 39b.. LICENSE.NUMBER 39c. _g TE SIGNED e, tl due to the cause(s), C.Y at of Ihe. physician, 40b. DATE SIGNED MM DD 1111 41b. DATE$IGNED JANE S. SMTTH STATE REGISTRAR 22. COUNTY OF DEATH Bonneville 26. TIME PRON0UNCE0 DEAD MM DD 1111 7.