HomeMy WebLinkAbout960690STATE OF WYOMING
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COUNTY OF LINCOLN
RECEIVED 8/25/2011 at 10:40 AM
RECEIVING 960690
BOOK: 771 PAGE: 617
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
this
AFFIDAVIT OF SURVIVORSHIP
Marilyn Johns, a /k/a Marilyn L. Johns, being first duly sworn on oath deposes and say:
1. That Marilyn Johns is of adult age and is the surviving wife of Roland Johns, who
died February 5, 2011, in Montpelier, ID, as hereinafter more fully appears.
2. That by a Warranty Deed dated October 1, 1963, and recorded September 9, 1966,
in the office of the Lincoln County Clerk in and for the County of Lincoln, State of Wyoming, in
Book 75 PR, Page 431, Melba Beyeler, a widow, to Roland Johns and Marilyn L. Johns,
husband and wife, by the entireties, of HC 63 Box 86, Cokeville, Wyoming 83119, Lincoln
County, State of Wyoming, the following described real estate situated in Lincoln County, State of
Wyoming, to -wit:
That property as more fully described on Exhibit "A" attached hereto and by this
reference made a part hereof.
3. That Roland Johns died on the 5 day of February. 2011, in Bear Lake County,
State of Idaho, and thereupon, the certificate of his death was duly filed with the State of Idaho and
made a matter of record in said office, and a certified copy of said certificate is attached hereto and
made a part of this affidavit.
4. That upon the death of Roland Johns, as aforesaid, the joint tenancy created by the
aforesaid deeds were terminated, and Marilyn Johns, surviving wife, became vested with all of her
right, title and estate in the above property.
DATED this day of
Marilyn L. Johi
U )3SCRIBED AND SWORN to before me by Marilyn Johns, a /k/a Marilyn L. Johns,
day of ctff,Cil 2011
B NEUENSCHWANDEP,
County of
Lincoln
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NOTARY PUBLIC
State of
Wyoming
August 31, 2014
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NOTARY PUBLIC
000617
WAR1-2ANT?i DEED -FORM NO,
.141
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Date Filed
DECEDENT LEGAL NAME
ROLAND JOHNS
SD( .SOCIAL SECURITY NUMBER AGE DATE OF BIRTH
MALE
84 YEARS AUGUST 21, 1926
BIRTHPLACE PLACEOFAESIDENCE
SMOOT, WYOMING. COKEVILLE, WYOMING
MARITAL STATUS AT TIME OF DEATH NAME OF SURVIVING Hire, maiden name) WAS AR FORCES?
DEDENT EVER IN
U.S
MARRIED MARILYN LANCASTER YES
FATHER -NAME BIRTHPLACE
WILLIAM JOHNS UTAH
MOTHER MAIDEN NAME BIRTHPLACE
VIVIAN A.L:BERTA;STALEY UTAH
METHOD OF DISPOSITION FUNERAL SERVICE LICENSEE:
REMOVAL FROM STATE DAVID N. MATTHEWS
NAMEAND ADDRESS OF FUNERAL FACILITY
MATTHEWS MORTUARY, INC., MONTPELIER, IDAHO
vn 1 c VI urn Ill TIME OF DEATH CITY,TOWN OR LOCATION OF DEATH COUNTY OF DEATH
FEB. 05, 2011 2:10 A.M. MONTPELIER, IDAHO BEAR LAKE
CAUSE OF DEATH (underlying cause last) Approximate Interval Between
a. Onset and Death
CONGESTIVE HEART FAILURE MONTHS
DUE TO (or as a consequence of):
b. CORONARY ARTERY DISEASE S/P BYPASS YEARS
DUE TO (or as a consequence of):
c
DUE TO (or as a consequence ot):.
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH but not resulting In the underlying cause given above WAS AN AUTOPSY
PERFORMED?
HYPOGLYCEMIA DIABETES BRADYCARD'IA NO
NATURAL
DATE'OFINJURY
LOCATION WHERE INJURY OCCURRED
DESCRIPTION OF HOW INJURY OCCURRED
FEBRUARY 17,
STATE OF IDAHO 0 0:0 6:1
IDAHO DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
CERTIFICATE OF DEATH
TIME OF INJURY
JACK 0. CLARK, M.D.
CORONER: SUBSEQUENT CERTIFICATION IF NECESSARY
PLACE OF INJURY
P? I J1t1
1
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This is a true and correct reproduction of the document officially registered and placed
on file with the IDAHO` BUREAU OF VITAL RECORDS ANDiHEALTH'STATISTICS.
This copy not valid unless: prepared on engraved border
displaying state seal and signature of The Registrar.
PBNCOI0.ao mm
JAMES B. AYDEL.OTTE
STATE 12EGISTRAR
StateFileNo 2011 -01313
INJURY AT
WORK?
CERTIFICATI t VITAL RECORD