HomeMy WebLinkAbout961738mmission Expires:
AFFIDAVIT TERMINATING ESTATE
File No.: 115742
STATE OF j,,ciz 0rY1 /e0
COUNTY OF ,Z.
I, Marjorie A. Johnson, being of lawful age and first duly sworn according to law, upon my
oath, depose and state:
1. That I am of adult age, a resident of `L L and the Affiant
herein.
2. That by virtue of the conveyances which are recorded in the office of the County Clerk for
Lincoln County, Wyoming, located at Kemmerer, Wyoming is recorded a Warranty Deed dated
the 5th day of August, 2010, in Book 751 PR on page 562 conveys unto Robert R. Johnson, Jr.
and Marjorie A. Johnson, Trustees, or their successors in trust, under The Johnson Family Trust
dated September 27, 1996 the following described property, to -wit:
3. That said Robert Royal Johnson aka Robert Royal Johnson, Sr. and Robert Johnson on the
10th day of October, 2010, died and a copy of the original certificate of death, certified to as true
and correct by public authority in which the original of said certificate is a matter of record, is
attached hereto as Exhibit "A
4. That by reason of death of said Robert Royal Johnson by reason of 2 -9 -102 W.S. (1980), the
decedents interest and title in said conveyance has terminated and title to the real property
conveyed thereby has vested absolutely in Marjorie A. Johnson, Trustee of the Johnson Family
Trust dated September 27, 1996, continuously since the death of the said decedent.
FURTHER AFFIANT SAYETH NOT.
W
Marjo A. Johnson
State of ACet d
)ss.
County of /jdy T
The foregoing instrument was subscribed and sworn to me by
Mp RJAR Ir A TOAb1 SUt� this day of M4/E's 1,SCK. a'0 f 1,
2011
and offic seal.
RECEIVED 11/4/2011 at 1:55 PM
RECEIVING 961738
BOOK: 775 PAGE: 653
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
o a CRAIG PATON
.1 Notary Public State of Florida
53 0FFo My Commission Expires 00 945246 f 4
000653
CERTIFICATION OF VITAL RECORD
TYPE OR
PRINT IN
PERMANENT
SUCK INR
DO NoT UBE
FELT TIP PEN
FOR
INSTRUCTIONS
SEE
HANOBCOKs
0 DEATH WAS
DuE To OTHER
THAN NATURAL
CAUSES.
THE CORONER
M
COMPLETE AND
SION THE
CERTIFICATE
OCT 2 2 2010
DATE ISSUED-
DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
#5 AMENDED 10 -22 -2010 CMW
DATE FILED BY STATE REGISTRAR: State Of Idaho
CERTIFICATE OF DEATH STATE FILE NO. 2010- -08565
10114/2010 Reg No.
INFORMANT
DISPOSITION
PLACE OF
DEATH
DATE OF
DEATH
ITEMS 32.38
TO BE USED
FOR EXTERNA
CAUSES ONLY
)CORONER)
1.DECEDENTS LEGAL NAME (Include AKA's if any) (First, Middle. Last. Suffix)
ROBERT ROYAL JOHNSON
t a 4a. AGE -Lass Birthday 4b UNDER 1 YEAR :eq. Hours 0ER 1 DAY 7 F (MOJDaylYO
Months Days Hours minutes 8
5� 8 L 1 LBIf�TI�J 31
5 79 (Years) X3'1
7a. RESIDENCE STATE OR FOREIGN COUNTRY :7b. COUNTY
o WYOMING LINCOLN
7d. STREE NUMBER
182 YELLOWSTONE DRIVE
m 8. MARITAL STATUS AT TIME OF DEATH
2. SEX 1. SOCIAL SECURITY NUMBER.
MALE
6. BIRTHPLACE (City and Slate, Territory. or Foreign Country)
SACRAMENTO, CALIFORNIA
7c. CITY OR TOWN
THAYNE
;7f. ZIP CODE 7 INSIDE 7e. APT. NO. I
g.
LIMITS? CITY
83127
Yes (E) No
9.SURVIVING SPOUSE'S NAME (If wile. give maiden name)
E 10 Married 0 Married. but separated 0 Wldawed 0 Divorced 0 Never married 0 Unknown MARJORIE ALICE PALMER
E
z ,10. EVER IN U.S. 11a. FATHER'S NAME (First Middle. Last, Suffix) 11b. BIRTHPLACE (Slate, Territory. Or Foreign Country)
•c ARMED
Z FORCES? ROBERT ROYAL JOHNSON SR ENGLAND
as
❑Yee 1Ta. MOTHER'S 1i1A10EN NAME (First, Middle. Last. Suffix) i12b. BIRTHPLACE Territory, or F oreign Cuunlry)
E 00 JESSAMINE PEARL DEEBACH MINNESOTA
U 13a. INFORMANT'S NAME (Type or print) '134. RELATIONSHIP TO DECEDENT 13c. MAILING ADDRESS (Street and Number, Cily, State, Ziptode)
Z MARJORIE ALICE JOHNSON WIFE P.O. BOX 816 THAYNE, WY 83127
14, METHOD OF DISPOSITION ,15. PLACE OF DISPOSITION (None and address of cemetery, i' 16. NAME AND COMPLETE ADDRE50 OF FUNERAL FACILITY
BurtaI I• Cramalion crematory, olher place)
Donati on 0 Entombment EAGLEROCK CREMATORY WOOD FUNERAL HOME
re D Remo I1 om Idal 273 NORTH RIDGE AVENUE 273 NORTH RIDGE AVENUE
0 ORlher(Sp oily) IDAHO FALLS IDAHO 83402' IDAHO FALLS, IDAHO 83401
"170. SIGNATURE OF FUNERAL SERVICOLICENSEE OR PERSON ACTING AS SUCH 17b. LICENSE NUMBER (Of licensee) 18, WAS CORONER CO TATTED
OUE TO CAUSE OF dEATH7
P ELECTRONICALLY FILED: CHRIS PETERSON M0778 0 Yes BM_
PLACE OF DEATH (19 -22)
193,1F DEATH OCCURRED IN A HOSPITAL: 194. IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
101npallenl 2 'DER/Outpatient 3 DOOA 40 Hospice facility 5 Nursing home /Long term care facility 60 Decedent's home 70 Other (Specify)
20.FACILITY NAME (II not lacilily, give street and number) 21. CITY, TOWN, OR LOCATION OF DEATH, AND ZIP CODE 22. COUNTY OF DEATH
LIFE CARE CENTER OF IDAHO FALLS IDAHO FALLS, ID 83406
23. DATE OF DEATH (Mo/DaytYr) (Spell month) 124. TIME OF DEATH (2441)! 25. DATE PRONOUNCED DEAD(MolDay/Yr) (Spell month)
October 8, 2010 07:30 October 8, 2010
27. CAUSE OF
PART 1. Enter the chain of events diseases, injuries. or complications -that directly caused the death. DO NOT enter termina' events such as cardiac
arrest. respiratory arrest, or venlricular fibrtlla9On without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line:
IMMEDIATE CAUSE (Final
disease or condition �p
resulting in death)
MYOCARDIAL INFARCTION
DUE TO (or as a consequence 01):
fi Sequentially Hs) conditions, b ATHEROSCLEROSIS
m if any, leading to the cause
o listed on line a. Enter the
h UNDERLYING CAUSE
LAST (disease or injury
that initialed the events
F, resulting in death)
d.
DUE TO (or as a consequence on'.
DUE TO (or as a consequence of)
n
r.
PART II. Enter other slq itiwnl contlilions conuibu11inq to death but not resulting in the e underlying cause given in Pan I
c !SOAS ABSCESS
g 29. DID TOBACCO USE 30. IF FEMALE (Aged 10 -54):
CONTRIBUTE TO DEATH? O Not pregnant within past year 0 Not pregnant. but pregnant 43 days
110 1 yea! before death
o. 0 Ves 0 Probably Pregnant at lime of death
E El No W Unknown 0 Not pregnant. but pregnant 0 Unknown it pregnant within the Pest
U within 42 days of death year
280. WAS AN AUTOPSY
PERFORMED?
❑Yes El No
31. MANNER OF DEATH
El Natural
Accident
0 Suicide
BONNEVILLE
TIME PRONOUNCED DEAD
1241111
07:30
Approximate Interval:
Onset to Death
10 MINS
30 YRS
285. WERE AUTOPSY FINDINGS
AVAILABLE TO C OMPLETE
THE CAUSE OF DEATH?
0 Yes 0 No
0 Homicide
Pending Investigation
0 Could nol be determined
32. DATE OF INJURY (MO /Day/Vr)
W (Spell month)
LL
F 36. LOCATION OF INJURY:
re
Stele
35. TIME OF INJURY (24hr)' 34. PLACE OF INJURY (Decedent's home, /arm. street. construction site,
nursing home, reslauranl,110,0811. elo.)
City/ Town or County
TRANSPORTATION 38a. WAS DECEDENT: 0 Driver /Operator 0 Passenger ;38b, WHAT SAFETY DEVICES(S) DID DECEDENT
INJURY ONLY 0 Podesloan 0 Other (Specify) 0 Seal belt 0 Child safely seal 0 Helmet
Zip Code
M 06919
35. INJURY AT WORK?
0 Yes 0 No
W Street and Number or Location Apartment Number
37. DESCRIBE HOW INJURY OCCURRED. IF TRANSPORTATION INJURY, STATE THE TYPES(S) OF VEHICLES) INVOLVED (Automobile. pickup, motorcycle, ATV, bicycle, etc.)
SPECIFY WHICH VEHICLE DECEDENT OCCUPIED. If applicable
USEIEMPLOY7
0 Alr bag 0 Nghe 0 Unknown
39b, LICENSE NUMBER
39a. CERTIFIER (Check, only one, based on official capacity for This certificate)
PHYSICIAN PHYSICIAN ASSISTANT ADVANCED PRACTICE PROFESSIONAL NURSE
To the best of my knowledge, death occurred al the lime, dale, and place, and due to the natural cause(s) /manner staled.
0 CORONER
On the basis 01 examination and /or investigation. in my opinion, death occurred al the lime, dale, and place. and due to the cause(s)
and manner slated.
Signature and Title of Certifier 11 ELECTRONICALLY SIGNED: WALLACE C. BAKER, M.D.
39d. NAME, ADDRESS, AND ZIP CODE OF CERTIFIER (Type or print)
WALLACE C. BAKER, 1880 JOHN ADAMS PARKWAY IDAHO FALLS, JD 83401
408. REGISTRAR'S SIGNATURE
405. DATE SIGNED
7 n10
This is a true and correct reproduction of the document officially registered and placed
on file with the IDAHO BUREAU OF VITAL RECORDS AND HEALTH STATISTICS.
This copy is not valid unless prepared on engraved border
displaying state seal and signature of the Registrar.
STATE OF IDAHO