HomeMy WebLinkAbout963813STATE OF WYOMING
)ss.
COUNTY OF LINCOLN
A parcel of land situate within the NW1/4SW of Section 24 to T21N,
R1 16W, described in particular as follows, to -wit:
AFFIDAVIT TERMINATING LIFE ESTATE
Beginning at a point North 26°14' East, 2222.4 feet from the southwest corner
of said Section 24; thence North 2 '17' East, 100 feet; thence North 87 °43'
West, 70 feet; thence South 2 °17' West, 100 feet; thence South 87 °43' East,
70 feet to the place of beginning, containing 7000 square feet, more or less.
ALSO: A parcel of land within the NW1/4SW1/4 of Section 24, T21N,
R116W of the Sixth Principal Meridian, Lincoln County Wyoming and
more particularly described as follows: Beginning at a point North 26°14'
East 2222.4 feet from the SW Corner of Section 24; thence South 2°17'
West 100 feet; thence North 87°43' West, 70 feet; thence North 2°17' East
100 feet; thence South 87 °43° East 70 feet to the point of beginning and
containing 7000 square feet, together with all buildings and improvements
thereon.
RESERVING and excepting therefrom, however, unto Anthony Borino, Jr.,
also known as Anton Borino, Jr., also known as Tony Borino, Jr. and
Rebecca E. Borino, also known as Becky Borino or the survivor the full use,
control, income from and possession of the property for and during their
natural life.
Lincoln, State of Wyoming.
00642
I, Karen Ann Farr, being of legal age and first duly sworn, depose and say as follows:
1. That Rebecca E. Borino, a/k/a Becky Borino, the decedent mentioned in the attached
certified copy of the certificate of death, is the same person as Rebecca E. Borino, a/k/a
Becky Borino named as one of the parties in that certai n Quitclaim Deed dated September
28, 2004, executed by Anthony Borino, Jr., a/k/a Anton Borino, Jr., a/k/a Tony Borino, Jr.
and Rebecca E. Borino, a/k/a Becky Borino to Karen Ann Farr, a married woman as her sole
and individual property, subject to a reserved life estate, recorded as Instniment #903204, on
September 29, 2004 in Book 568 at Page 518, of the Official Records of Lincoln County,
State of Wyoming, concerning the real property situated in the County of Lincoln, State of
Wyoming and described as follows:
2. That an Affidavit Terminating Life Estate was filed in the Office of the Lincoln County Clerk
in Book 678 at Pages 475, 476, and 477 as Receiving #934814 on November 13, 2007
terminating the life estate of Anthony Borino, Jr., a/k /a Anton Borino, Jr., a/k/a Tony Borino,
Jr. who died on the 11"' day of September, 2007, in the City of Kemmerer, County of
RECEIVED 3/26/2012 at 2:06 PM
RECEIVING 963813
BOOK: 783 PAGE: 642
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
3. That I am the same Karen Ann Farr mentioned in the above referenced Quitclaim Deed and
thereby am a person interested in the effective property or the title thereto and pursuant to
2 -9 -102 W.S. (1980) hereby make the death a matter of record and certify that upon the
death of Rebecca E. Borino, a/k/a Becky Borino, her previous life estate in the property was
terminated.
4. That the certified copy of the certificate of death indicates that Rebecca E. Borino, a /k/a
Becky Borino died on the 16`'' day of January, 2012, in the City of Tucson, County of Pima,
State of Arizona.
Dated this day of 2012.
STATE OF ARIZONA
ss.
COUNTY OF PIMA
Q J 4 1% 't /1.-
KAREN ANN FARR
00643
This Affidavit Terminating Life Estate was signed and sworn before me on this ;77 day
of /IAA 2012 by Karen Ann Farr.
DIANE TRUJILLO
Notary Public Arizona Notary Public t
Pima County My Commission Expires: 20 /..c
My Comm. Expires Sep 1, 2015 l
1. DECEDENT'S LEGAL NAME (FIRST, MIDDLE, LAST)
REBECCA ELLEN BORINO
2. AKAS (IF ANY)
3, DATE OF DEATH
JANUARY 16, 2012
4. SEX
FEMALE
5. SOCIAL SECURITY NUMBER:
520-38-0984
6. DATE OF BIRTH
05-19-1917
7 AGE
94
UNDER 1 YEAR
UNDER 1 DAY
8. MONTHS
9. DAYS
10 HOURS 11 MINUTES
1.
12. PLACE OF DEATH HOSPITAL
III INPATIENT E.R.IOUTPATIENT DEAD ON ARRIVAL
13. PLACE OF DEATH OTHER THAN HOSPITAL:
NURSING HOME OR LONG TERNI CARE FACIUTY MI RESIDENCE 1/1 HOSPICE FACILITY Ul OTHER RESIDENCE
14. FACILITY NAME (OR STREET ADDRESS IF NOT A FACILITY):
8950 SOUTH WILTBANK ROAD
C.ITY, TOWN &ZIP CODE OR LOCATION OF DEATH:
T UCSON 85737
16. COUNTY OF DEATH:
PIMA
17. BIRTHPLACE (CITY AND STATE OR FOREIGN COUNTRY)
BURR OAK, INDIANA
18. MARITAL STATUS AT TIME OF
DEATH:
WIDOWED
19 NAME OF SURVIVING SPOUSE (MAIDEN NAME IF WIFE)
20. DECEDENT'S USUAL RESIDENCE STREET ADDRESS: 121. CITY AND COUNTY:
34 CHICAGO ST, plAMONDVILLE, LINCOLN
22. STATE
WYOMING
23 ZIP CODE
83116
24. EVER IN THE ARMED
FORCES
NO
25. WAS DECEDENT OF HISPANIC ORIGIN?
IN NO, NOT SPANISH, HISPANIC OR LATINO
El YES, MEXICAN, MEXICAN AMERICAN, CHICANO
13 YES, PUERTO RICAN
0 YES, CUBAN
13 YES, OTHER (SPECIFY)
26. DECEDENT'S RACE(S):
BLACK WHITE AFRICAN AMERICAN OTHER ASIAN (SPEC FY)
13 NATIVE HAWAIIAN
27. IF AMERICAN INDIAN OR ALASKA NATIVE.
SPECIFY UP TO 4 TRIBES,
PRIMARY OR ENROLLED TR/BE.
13 ASIAN INDIAN 0 OTHER PACIFIC ISLANDER (SPECIFY)
0 CHINESE
CI FILIPINO
ADOMONAL TRIBE:
13 JAPANESE
0 OUAMANIAN OR CHAMORRO 0 0114 (SPECIFY)
0 KOREAN
ADDITIONAL TRIBE
0 UNKNOWN
0 VIETNAMESE
0 SAMOAN 13 UNKNOWN
a AMERICAN INDIAN OR ALASKA NATIVE
ADDMIDNAL TREE
28. OCCUPATION:
HOMEMAKER
29. FATHER'S NAME (FIRST, MIDDLE, LAST)
CHARLES L. HATTEN
30. MOTHER'S NAME (FIRST, MIDDLE, LAST NAME PRIOR TO FIRST MARRIAGE)
EFFIE DRUSILLA EMIGH
31. INFORMANT'S NAME
KAREN FARR
32.RELATIONSHIP
DAUGHTER
33. INFORMANTS MAILING ADDRESS
11200 S SIERRITA MOUNTAIN RD PMB 315, TUCSON, ARIZONA 85736
34. NAME AND ADDRESS OF FUNERAL FACILITY:
BRING'S MEMORIAL CHAPEL 236 S. SCOTT AVE TUCSON, AZ
35. FUNERAL DIRECTOR:
36. LICENSE
NUMBER:
F1204
FRANK J E ERSON FUNERAL DIRECTOR
37. NIETHOD(S) OF DISPOSITION:
REMOVAL/BURIAL
38. NAME AND LOCATION OF 1st DISPOSITION FACILITY:
SOUTH LINCOLN CEMETERY, KEMMERER, WYOMING
39. NAME AND LOCATION OF 2nd DISPOSITION FACILITY:
NONE
IMMEDIATE CAUSE
OF DEATH
40. A
ATHEROSCLEROTIC CARDIOVASCULAR DISEASE
41. APPROXIMATE INTERVAL
UNKNOWN
DUE 70 011 AS A
CONSEQUENCE OF
42.8
43, APPROXIMATE INTERVAL
DUE TO OR AS A
CONSEQUENCE OF
44. C
45. APPROXIMATE INTERVAL.
DUE 70 011 AS A
CONSEOLIENCE OF:
4E 0
47. APPROXIMATE
NTEFIVAL:
TAUPE OF DEM R
PT 11 ''f''
48. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING
IN THE UNDERLYING CAUSES GIVEN ABOVE
HYPERTENSIVE CARDIOVASCULAR DISEASE
49. INJURY'
NO
50. INJURY AT WORK?
NO
51. MANNER OF DEATH
NATURAL DEATH
‘v
52 TIME OF DEATH
2103
51 WAS AN AUTOPSY PERFORMED?
NO
54. WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETETHE CAUSE OF DEATH?
0•4, n,.4'.; :Mv*.zei,-,%%::;9: 'CAM AND MANNER OF TH :DEA CERTIFICATION
-,vx
1 l'.
0 Certifying PhysitianoNurse Practitioner/Physician's Assistant To the best of my
knowledge, death occurred due to the cause(s) and manner stated.
eS n d end d
due to the cause(s) and manner stated_
sa NAME OF PERSON COMPLETING CAUSE OF DEATH:
CYNTHIA M PORTERFIELD, D.O.
56. DATE CERTIFIED:
01-17-2012
57. CERTIFIER'S ADDRESS:
2825 E DISTRICT STREET TUCSON, AZ 85714
58. NAME OF REGISTRAR:
AUDR ROGERS
59 DATE REGISTERED
01-18-2012
Date Issued: 01-20-2012
STATE OF ARIZONA
DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS
CERTIFICATE OF DEATH State File NO. 102-2012-001179
This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS,
ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA.
Revised 04/2010
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
A r i 7011.1
Department of
iealth Services