HomeMy WebLinkAbout962341File No.: 118660
STATE OF WYOMING
COUNTY OF LINCOLN
AFFIDAVIT TERMINATING ESTATE
I, Sharon L. Nielson, 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 Thayne, Wyoming, 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 5 day of November, 2003, in Book 541PR on page 365 conveys unto John D. Nielson
and Sharon L. Nielson the following described property, to -wit:
Lot 61 of Star Valley Ranch, Plat 10, Lincoln County, Wyoming as described on the official plat
filed March 16, 1976 as Instrument No. 476273 of the Records of Lincoln County Clerk.
3. That said John D. Nielson on the 16th day of ?!ray 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 John D. Nielson 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 Sharon L. Nielson continuously since the death of
the said decedent.
FURTHER AFFIANT SAYETH NOT.
December 9, 2011
State of Wyoming)
County of Lincoln)
The foregoing instrument was subscribed and sworn to me by Sharon L. Nielson, this
day of December, 2011
Witness my hand and official seal.
`Ire's JL, 2
Notary Public
My Commission Expires:
9 /5 -/s
0 0842
RECEIVED 12/14/2011 at 1:53 PM
RECEIVING 962341
BOOK: 777 PAGE: 842
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
GLORIA K. BYERS NOTARY PUBLIC
County of si State of
Lincoln C Wyoming
My Commisson Expires September 15, 2015
9�'
Date Filed
JUNE 09, 2010
DECEDENT• LEGAL NAME
JOHN DEASY NIELSON
SEX SOCIAL SECURITY NUMBER AGE DATE OF BIRTH
MALE 73 YEARS MARCH 10, 1937
BIRTHPLACE PLACE OF RESIDENCE
BLANDING, UTAH STAR VALLEY RANCH, WYOMING
MARITAL STATUS AT TIME OF DEATH NAME OF BURNING SPOUSE (II Mite, maiden name) WAS DECEDENT EVER IN
U.S. ARMED FORCES?
MARRIED SHARON LOUISE PENDLEBURY NO
FATHER NAME _1 BIRTHPLACE
MORGAN LEON NIELSON MEXI6O
MOTHER MAIDEN NAME BIRTHPLACE
HELEN DEASY MASSACHUSETTS
METHOD OF DISPOSITION
REMOVAL FROM STATE
NAME AND ADDRESS OF FUNERAL FACILITY
I r„a
NAME AND ADDRESS OF FUNERAL FACILITY
NALDER'S FUNERAL HOME, SHELLEY, IDAHO
....-r.,, L �„r,,.,rvn un �vv,.,ivry yr ucn,n UUUNIYUI USAIH
MAY, 16, 2010 I 2:10 P.M. IDAHO FALLS, IDAHO BONNEVILLE
CAUSE OF DEATH (underlying cause last) A3proximate Interval Between
a Onset and Death
SEPTIC SHOCK WITH HYPDXEMIA FROM ACUTE RESPIRATORY DISTRESS 1 DAY
DUE TO (or as a consequence of):
b SYSTEMIC INFLAMMATORY RESPONSE SYND WITH MULTI -ORGAN FAILURE 3 DAYS
DUE TO (or as a consequence of):
'TUMOR LYSIS SYNDROME 6 DAYS
DUE TO (or as a consequence of):
'ACUTE MYELOGENOUS LEUKEMIA 3 MONTHS
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH but not resulting in the underlying cadre given above WAS AN AUTOPSY
PERFORMED?
DIABETES CORONARY ARTERY DISEASE NO
MANNER OF DEATH NAME OF CERTIFIER TITLE
NATURAL JOHNG. MILLER, M.D. PHYSICIAN
CORONER SUBSEQUENT CERTIFICATION IF NECESSARY
7�1°�ftN�L
DATE OF INJURY TIME OF INJURY PLACE OF I WURt' U' JURY
WORK?
LOCATION WHERE INJURY OCCURRED
DESCRIPTION OF HOW INJURY OCCURRED
l ll�; JUNE 09, 2010
00 DATE ISSUED•
This copy is not valid unless prepared on engraved border
displaying state seal and signature of the Registrar.
CERTIFICATE. OF DEATH
STATE OF IDAHO
DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
FUNERAL SERJIPE LICENSEE
JASON P. MECHAM
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.
JANE S. SMITH
STATE REGISTRAR
State File No 2010 -04762
EMQ
CERTIFICATION OF VITAL RECORD