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Home My WebLink About961407State of WY County of Lincoln ss. J. Robert Lavery, being first duly sworn upon His /Her oath, deposes and states as follows: 1.On the September 11, 2003, my husband /wife, Margaret Mary Lavery passed away, as is evidenced by the official certificate of death attached hereto and incorporated herein by this reference. 2. At the time of death my wife /husband jointly owned certain real property with me, said real property being located in the County of Lincoln State of Wyoming, and more particularly described as follows: Lot Forty -Six (46) in Star Valley Ranch Plat Nine (9) as Platted and recorded in the official records of Lincoln County, Wyoming 3. Said real property was originally conveyed to J. Robert Lavery and Margaret M. Lavery, husband and Wife, as tenants by the entireties, by Warranty Deed, dated August 31, 1992, and recorded in the office of the Lincoln County Clerk and Ex- Officio Register of Deeds on September 8, 1192, in Book 315PR at Page #124. 4. By reason of Margaret Mary Lavery death, I am entitled to sole ownership of the above mentioned real property. Dated this October 13, 2011 Subscribed and Sworn to and acknowledged before me this J. Robert Lavery. Witness my hand and official seal. Dyanna Parker Notary Public County of hh 1 State of Lincoln Wyoming My Commission Expires June 29, 201 Affidavit of Survivorship Rob-rt Lavery Notary(Public IL) 000448 DO I by RECEIVED 10/14/2011 at 11:52 AM RECEIVING 961407 BOOK: 774 PAGE: 448 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY DECEDENT 1. NAME OF DECEDENT FIRST' MIDDLE. LAST Margaret Mary LAVERY 2. SEX Female 3a. DATE OF DEATH (Mo., Day, Yr.) September 11 2003 35. TIME OF DEATH (24 hr. clock) 0852 4. DATE OF BIRTH (Mo., Day, Yr.) Janus. 2424 1933 :AGE- Last Birthday '70 IF UNDER o 1 YEAR IF UNDER 24 HRS. mu 6. BIRTHPLACE St. 8b. NAME OF (ifoutside U n i v e (City 8 State or Foreign Country) Louis, MO. 7. SOCIAL SECURITY NUMBER 8a. PLACE HOB SPITAL (stems codes Wr Hospeel ALL OTHER LOCATIONS: OF DEATH (check o n l y 1 1 Inpatient O 5. Nursing Home 6. Residence (any) J 7. Other (specify) one) L1 2. ERIOulpatienl D I 3. DOA, HOSPITAL, NURSING HOME OR OTHER FACILITY a facility, give street address of location) r s i t y Ho s p i to 1 SPOUSE (if wife, give maiden name) Robert Lavery `I 8c. CITY, TOWN, OR LOCATION OF'DEATH Salt Lake City.. 8d. COUNTY OF DEATH Salt Lake 9. SURVIVING J. 10. WAS DECEDENT EVER IN THE U.S. ARMED FORCES? 1. Yes 2. No 11. MARITAL STATUS Ell 1. Never Married 3: Widowed W 2. Married ®;4. Divorced 120. DECEDENT'S USUAL OCCUPATION (Give kind of work done during most of working life. Do NOT enter retired) Homemaker 12b. KIND OF BUSINESS OR INDUSTRY Own Home 13e. RESIDENCE STREET AND NUMBER F -Q.__13. 12 13b. CITY, TOWN OR COMMUNITY Tha e 13c. COUNTY Lincoln 13d. STATE WY. 13e. INSIDE CITY LIMITS? L-lU 1. Yes LI 2. No 13f. ZIP CODE' 83127 '14: WAS'OECEDENT OF HISPANIC ORIGIN? (it yes, Specify) `1, Mexican 2. Cuban 3.PUerto Rican III 4 Other (Specify) I 1. Yes RI 2. No 15. RACE Black, While, Am. Indian (Tribe may be entered), Japanese, etc. (Specify) White 16. EDUCATION (specify only highest grade completed) Elementary or Secondary (0-12) College,(13 -16 or 17+) -17- PARENTS 17. FATHERS NAME (First, Middle, Lest)` Arthur Jams T7ons 18. MAIDEN NAME OF MOTHER (Fos( Middle, Last) MarFaret. Mar Yoc-h INFORMANT 19. NAME, RELATIONSHIP AND MAILING OF INFORMANT J. Robert Lavery T ''i P.O. Box 101?. Thayne, WY. 8319,7 DISPOSITION 20. METHOD OF DISPOSITION• 171 1. Entombment. 2. Donation In 3 4. Burial 5. Cremation 6. Removal 21a.'DATE OF DISPOSITION September 15, 2003 21b. PLACE OF DISPOSITION (name 0 /cemetery, crematory, or other place) Brigham. City Cemetery fl. r 21c. LOCATION City or Town, State Brigham City, UT. Olen, TIT. 22. SIGNATUr FUNE• E '!CONS 1` I 23. LICENSER 221141120902 24. FUNERAL HOME (Name and address) Mortuary 84302 CERTIFIER 25. DATE DECEASED LAST ('26. ATTENDED BY CER PING PHYSIC!' s September 11 2003 )(not certified by medical examiner, was death reported to M.E.7 CJ 1. Yes 2. No If yes;•enter the date and hour reported. :,,A. cAS HR. MO_ DAY 205 South 100 East Brigham City, UT. t 27a, CERTIFIER i^ 1 1. CERTIFYING PHYSICIAN: To the: best of my knowledge, death occurred at the _YEAR lime, dale, and place, and due to the cause(s) and m nner as staled. El 2. MEDICAL EXAMINER/LAW ENFORCEMENT OFFICIAL: On the basis of examination and/or investigation, in my opinion, death occurred at the time, date, piece and due to the cause(s) and manner as stated. 27b. SIGNATURE AND TITLE OF CERTIFIER lu ll Shel)�0 J�tmei t MA 27c. LICENSE NUMBER 522 ta(O -i. 1LO5' 27d. DATE SIGNED (Month, Day, Year) 7 /(2-16 3 28. NAME AND ADORES OF PER ON WMO.CERYIFIED THE r E OF D EATH (I 132 Ty dnt) L%� /kV e 1 r� REGISTRAR 29, REGISTRAR'S SIG Joey 30a. DATE REGIS NOTIED OF DEATH (Mo., Day, Yr) 30b. DATE FILED (Mo., Day, Yr) September 19, 2003 CAUSE OF DEATH UDH -BVR Form 12, Rev. 12/98 31. ARTTHE DISEA INJN OR COMPLICATIONS THAT CAUSED THE DEATH. DO NOT ENTER THE MODE OF DYING. SUCH AS CARDIAC I Approximate Interval OR RESPIRATOR ES`f :SHOCK, OR:HEART FAILURE. LIST ONLY ONE CAUSE ON EACH LINE. Between Onset and IMMEDIATE CAUSE (Final c I Deist V disease or condition resulting TIC g in death) (((2!1 AS A NSEQUENCE OF �l Sequentially list conditions, 0 DUE TO (OR AS A CONSEQUENCE OF): any, leading to immediate cause. Enter UNDERLYING c, CAUSE (disease or injury that, .DUE TO (OR AS A CONSEQUENCE OF): initiated events resulting in death) LAST PART II. Other Significant Conditions contributing 10 deetp but not resulting In /he underlying cause given in Part 1 32. IN YOUR OPINION, TOBACCO USE BY THE DECEDENT: 1. Probably contributed to the cause of death. 5. NON USER 2. Was the underlying cause of death. 33a. WAS AN AUTOPSY PERFORMED? 1. Yes fit. No 33b. WERE AUTOPSY FINDINGS AVAILABLE PRIOR TO COMPLETION OF CAUSE OF DEATH? O 1. Yes U 2. No 3. Did not contribute to the cause of death. 6. U F NKNO USER WN I .4. Is unknown in relation to the cause of death. 34. MANNER OF DEATH 1. Natural 0 2. Accident '35a.`DATE OF INJURY (Mo., Day, Yr.) 35b. TIME OF INJURY (24 Hour Clock) 35c. INJURY AT WORK? 1. Yes 2. No 35d. PLACE OF INJURY At At home, farm, slreeL' factory, office, building, eta. (spe 0 3. Suicide 0 4. Homicide �5. Undetermined[] 6. Pending 35e: LOCATION (Street or rural route number, city or town county and state.) m 35f If motor vehicle accident specify if decedent was driver, passenger or pedestrian. II injured in Purposely or Accidently 355. DESCRIBE HOW INJURY OCCURRED (enter sequence o/ events which resulted in in'ury, NATURE OF INJURY should be entered in item 31) a z rn rn Date Issued: rn Access m Information on STATE,OFUTAH DEPARTMENT OF HEALTH Ks form eSneed ender Aa LOCAL FILE NUMBER CERTIFICATE OF DEATH Ii,e Veal atausllco 18- 4247 and Rules. This 's to certify that this is a true copy ;ofthe certificate on file in this office. This certified copy is issued under authority of section 26 -2 -22 of the Utah Code Annotated, 1953 As Amended. Barry E. Nangle DIRECTOR OF VITAL RECORDS 111111 11111111111 1 By LL 0132 4099 0 1 3 2 4 D 9 9 SEPTEMBER 22, 2003 ci County SALT LAKE Ca Registrar c a ve, 11 STATE FILE NUMBER WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATION.