HomeMy WebLinkAbout960777STATE OF WYOMING
COUNTY OF LINCOLN
Ss.
AFFIDAVIT OF SURVIVORSHIP
000863
Patricia F. Rubke of 1745 North 125th Drive, Avondale, AZ 85392, upon her oath deposes
and says:
1. That ARVIN RALPH ROBERTSON aka Arvin R. Robertson, the decedent mentioned
in the attached copy of State of Arizona Certificate of Death, is the same person as ARVIN R.
ROBERTSON named as one of the grantees in that certain Warranty Deed dated the 25th day of
June, 1996, executed by Leisure Valley, Inc., grantor, and recorded July 25, 1996, in Book 386 PR,
page 126, of the Official Records of Lincoln County, Wyoming, covering the following described
real property located in Lincoln County, Wyoming, to -wit:
STAR VALLEY RANCH RV PARK Plat One Lot 62 as platted and recorded in the
Official Records of Lincoln County, Wyoming.
2. That the undersigned affiant, Patricia F. Rubke, is the daughter of the named
grantees in the above described Warranty Deed, that ARVIN RALPH ROBERTSON and Barbara
Jean Robertson were husband and wife at the time of the execution and recording of the Warranty
Deed described above, and that as the surviving cotenant and spouse of ARVIN RALPH
ROBERTSON, named in said conveyance, Barbara Jean Robertson, became on May 16, 2007, the
date of the death of the aforementioned decedent, the owner of the lands or the owner of any
interest of ARVIN RALPH ROBERTSON, in the lands described in the foregoing, subject to any
then existing liens and encumbrances.
DATED as of the 29th day of August, 2011.
RECEIVED 8/31/2011 at 11:18 AM
RECEIVING 960777
BOOK: 771 PAGE: 863
JEANNE WAGNER
1 N COUNTY CLERK, KEMMERER, WY
1
Patricia F. Rubk
Subscribed and sworn to by Patricia F. Rubke before me this 29th day of August, 2011.
Witness my hand and official seal.
GERALD L. GOULDING NOTARY PUBLIC
County of r State of
Lincoln :fA Wyoming
My Commission Expires May 2, 2015
My commission expires: May 2, 2015.
2
NOTARY PUBLIC
0u08(4
IFI
ORIGINAL
STATE
COPY
30. SIGNATURE 4-0 AND TITLE I
STATE OF ARIZONA
1
PLACE OF
DEATH
6.MARICOPA
6A. COUNTY
DATE OF MONTH DAY YEAR
BIRTH
7 DECEMBER 17', 1929
STATE AND (11 not in USA, name country)
CITY OF BIRTH
EVERTON ARKANSAS
USUAL 15A. STATE
RESIDENCE
15. ARIZONA
STREET ADDRESS OF R.F.D.
15E1011 N LOS ROBLES DR
FATHERS
NAME
19.
A. FIRST B. MIDDLE
SAMUEL WASHINGTON
C. LAST
ROBERTSON
r
NAME OF
DECEASED
A. FIRST
ARVIN
B. MIDDLE
RALPH
C. LAST
ROBERTSON
RACE (e.g., white, black, American Indian, (specify tribe)etc:
SPECIFY:
4A. WHITE
INFORMANT'S SIGNATURE
24 BARBARA J ROBERTSON
15B. COUNTY
MARICOPA
WAS DECEDENT OF HISPANIC ORIGIN:
(SPECIFY YES OR NO)
48. NO
6B. TOWN OR CITY
SURPRISE
AGE (YEARS
LAST BIRTHDAY)
8A 77
CITIZEN OF WHAT SPECIFY
COUNTRY?
12. U S A
INSIDE CITY UMITS?
(SPECIFY Yes or No)
15F. YES
IF UNDER 1 YEAR
MOS. DAYS
8B.
15C. TOWN OR CITY
GOODYEAR
IF UNDER 1 DAY
HRS. MIN.
BC.
ON RESERVATIONS
(SPECIFY Yes or No)
15G. NO
RELATIONSHIP TO
DECEASED
WIFE
SEX
2. MALE
IF YES, INDICATE MEXICAN, SPANISH, PUERTO RICAN,
CUBAN, ETC.
4C.
6C. HOSPITAL OR (IF RESIDENCE, GIVE STREET ADDRESS)
INSTITUTION
HOSPICE OF THE VALLEY
MARRIED, NEVER MARRIED,
WIDOWED, DIVORCED (SPECIFY)
9. MARRIED
SOCIAL SECURITY NO.
13.
15D. ZIP CODE
85338,
USUAL OCCUPATION (Give kind of work
done most of working life, even if retired)
14A. MILITABI
HOW LONG IN ARIZONA?
16.. 40 YEARS
PREVIOUS STATE
OF RESIDENCE
18. ENGLAND
DATE OF MONTH
DEATH
3. MAY 16, 2007
17.
A. FIRST B. MIDDLE
'EMBALMER'S SIGNATURE
27A 10 NOT EMBALMED
WAS DECEASED EVER IN U.S. ARMED
(SPECIFY YES OR NO)
5, YES
148. U S AIRF
ELEMENTARY SECONDARY
(0-12)
18A. 12
FUN ER c •f....•Ca
29A. 0 T B RADLE
18B.
C. LAST
TURE)
STATE OF ARIZONA
DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS
CERTIFICATE OF DEATH
BURIAL, CREMATION, DATE 4s •e RY NAME/LOCATION
REMOVAL, OTHER (Specify) GREENWOO b MEMORY' LAWN CREMATORY
CREMATION 25 .05 /25/2007 25 PHOENIX' ARIZONA
FUNERAL HOME NAME STREET ADDRESS CITY AND STATE
ADVANTAGE FUNERAL CREMATION SERVICES MARYVALE CHAPEL
28. 6901 W INDIAN. SCHOOL RD PHOENIX ARIZONA 85033
I TO V-IE BEST OF MY l30OWLCUGc. DEATI I OCCURRED Ai THE ,ME, DA 7E" E AND PLAGE
DUE TO THE CAUSE(S) STATED
1
1
D fi j T•IH REC 71 ST F T.
2001
47 I
q z a.
z V
DATE SIGNS, i'Day, Year)
31. f C..""'rt,' 7
NAME OF ATTENDING PHYSICIAN OF OTHER THAN CERTIFIER (Type or print)
33.
NAME AND ADDRESS OF CERTIFIER, PHYSICIAN, MEDICAL EXAMINER. OR TRIBAL LAW ENFORCEMENT AUTHORITY
3 lffl.r6 P KE GUERRERO'MD 14066 W WADDELL RD SURPRISE ARIZONA 85379
REG. FILE NO.
43. 10929
PART II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I
48. l-C%e r -CDfY ti" 4 V S 1t o9.A'' o/ ..1
MANNER OF DEATH
N4TR./
DnUFES
7LQOBJT
51.
FCMOCE
INhSRCATICN
SUOCE LNDET6 VINED
I SUPPLEMENTARY ENTRIES
58.
47A. IMMEDIATE CAUSE (FINAL DISEASE OR CONDITI uN RESULTING 15 DE' H) (ENTER 0 Y ON CAUSE ON EACH LINE)
/re' e 4075 Ac," ■x ,4
478. DUE TO OR AS A CONSEQUENCE OF:
47C. DUE TO OR AS A CONSEQUENCE OF:
DATE OF
INJURY
52.
MO DAY YR HOUR
53.
PLACE OF INJURY (At home, farm, street, factory, office building, etc.)
SPECIFY
56.
REGISTRAR' SIGNAT
44. 10'
HOUR OF DEATH
32. 7:30 AN
(Specify Yes or No)
54.
DATE, SIGNED (Mo., Day, Year)
PRONOUNCED DEAD (Mo., Day, Year)
AUTHORIZED FOR CREMATION
(SPECIFY)
40. IQ Yes No
AUTOPSY
(Specify Yes or No)
41 NO
INJURY AT WORK? DESCRIBE HOW INJURY OCCURRED
55.
I WHERE LOCATED? STREET ADDRESS
57.
WAS CASE REFERRED
(Specify Yes or No)
50. YES
MOTHER'S MAIDEN
NAME
20. GERTHA MAE WOOD
ADDRESS STREET NO. CITY AND STATE ZIP CODE
231011 LOS ROBLES DR GOODYEAR ARIZONA 85338
298E 1100
ON THE BASIS OF EXAMINATION AND /OR INVESTIGATION, IN MY OPINION DEAL H OCCURRED
AT THE TIME, DATE ANOPLACE DUE TO THE CAUSE(S) AND MANNER STATED.
34 SIGNATURE
AND TITLE
•L T• •T L
DEATH NO.
0U0865
D -102 tr'
l -�i )rr 0•i q
8269
SD.
DOA
O OP EMER.
IN PATIENT
SURVIVING (IF WIFE, GIVE MAIDEN NAME)
SPOUSE
,g. BARBARA JUNIPER
KIND OF BUSINESS OR INDUSTRY
CITY OR TOWN
Jun 7,2007
This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS,
ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA issued under
the authority of A.R.S. 36 -341, and by direction of:
This copy not valid unless prepared on a form displaying the State Seal and impressed with the raised seal of the issuing agency.
PATRICIA ADAMS
ASSISTANT STATE REGISTRAR
DAY YEAR
EDUCATION
HIGHEST GRADE COMPLETED
HOUR OF DEATH
36.
PRONOUNCED DEAD (Hour)
38. AT
STATE OFFICE
FORCES?
ORCE
COLLEGE
(1-4 or 5+)
CERT. NO.
278.
CERT. NO.
APPROXIMATE
INTERVAL
BETWEEN
ONSET
AND
DEATH
TO MEDICAL EXAMINER
STATE
•TI• k T r
ANY ALTERATION OR ERASURE VOIDS THIS DOCUMENT 1'
A /CAF .I .AAp ?S
CERTIFICATION OF VITAL RECORD
•AB F•• 1 •R:R •T. IT. r
A9'I /(511a
Department Of
Iieaitii Services
'�V