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Affidavit of Survivorship
I, Charles Ferrarini, Jr., being of lawful age and duly sworn according to law,
upon my oath, depose and state:
That under the date of August 7, 2001, for valuable consideration, Michael
Carera, Jo Ann Capellen, Charles Ferrarini, Jr. aka Charles Ferarini, Jr. and Michael
Ferrarini, by deed of that date, which deed was duly filed of record in the Office of the
Lincoln County Clerk, on August 10, 2001, in Book 47oPR, Page 416, conveyed to
Michael Carera, Patsy R. Ellsworth, Jo Ann Capellen, Charles Ferrarini, Jr. and Michael
Ferrarini, as joint tenants, the following described land, in the County of Lincoln, State
of Wyoming, to -wit:
Lot 1 of Block 52 of the Second Addition to the Town of Kemmerer, Lincoln County,
Wyoming as described on the official plat thereof
That by reason of said conveyance aforesaid, the said Michael Carera, Patsy R.
Ellsworth, Jo Ann Capellen, Charles Ferrarini, Jr. and Michael Ferrarini, as joint
tenants, became the owners of said real property, and the title thereto vested in them
continuously from the date of said conveyance, to the date of death of Michael Carera, on
the 22nd day of August, 2011. That by reason of and upon the death of Michael Carera,
title in the above described real property vested in Patsy R. Ellsworth, Jo Ann Capellen,
Charles Ferrarini, Jr. and Michael Ferrarini, as joint tenants.
Affiant avers and certifies that Michael Carera is the identical party named with
Patsy R. Ellsworth, Jo Ann Capellen, Charles Ferrarini, Jr. and Michael Ferrarini in the
aforementioned deed, whose death terminated his interest, title and estate in said real
property; and Affiant attaches hereto, and makes a part of this affidavit, a copy of the
Official Certificate of Death of said decedent, duly certified by the public authority in
which said death certificate is a matter of record.
Dated this k 1't- day of 2012.
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My Commis`Siq p.i �S: 1GI Dtr"t
Charles Fer Parini, Jr.
Subscribed and sworn to before me, a notary public in and for said County and
State, by Charley Eerrrarini, Jr., this] 1 i day of 2
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Notary Public
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fJS f,, CERTIFICATI SY
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
Decedent: State File Number: 201 1 002496
Name: Michael Carera
Gender: Male Social Security Number:
Date of Birth: August 11, 1923 Age at the Time of Death: 88 years
Date and Place of Death:
Date of Death: August 22, 2011 County of Death: Uinta
City of Death: Evanston
Location: Rocky Mountain Care. 475 Yellow Creek Rd
Additional Decedent Information:
Place of Birth: Frontier, Wyoming
Residence: Kemmerer, Wyoming
Marital Status: Married Patsy Ellsworth
Armed Forces: No
Name of Father: Mike Cistola
Name of Mother: Ann Warhol
Informant: Patsy Ellsworth Relationship: Wife
Disposition:
Method of Disposition: Cremation
Place of Disposition: Garner Crematory, Salt Lake City, UT.
Funeral Home or Facility:
Facility: Ball Family Chapel, Evanston, Wyoming
Cause of Death:
The immediate cause is listed on the first line followed by any underlying causes. Interval:
(a) Probable Myocardial Event Min.
(b) Hip Fracture Days.
Other Significant
Conditions:
Manner of Death:
Injury Information:
Date Of Injury: August 07, 2011 (Actual) Time Of Injury: Approximate 16:30 ±1 hr
Hu, y At Vvurk? No
Location: 1100 Cedar Street, Kemmerer, Wyoming
Description: Victim fell outside his home: watering the lawn,! and fractured his hip. Had surgery on 8/11/11.
Entered Nursing Home 8/16/11.
Certifier:
Type: Coroner
Name: William Ball, Deputyporoner
Address: 800 Uinta Street, Evanston, Wyoming, 82930
Date Filed: August 26, 2011
546952
Accident Time of Death: 21:00 (Actual)
ltti�i This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming;
a� vs: DATE ISSUED: Thursday, September 01, 2011
ill y' This copy is n t paper .border. valid unless prepared on er with an
JJt� IY P P PP
Matthew T. Rowe
Interim Deputy State Registrar
Cindy. K. Dr a.J
Il
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ITAL RECORD
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