HomeMy WebLinkAbout964270STATE OF WYOMING
COUNTY OF LINCOLN
ss.
I, DEBORAH A. LYNCH, being of legal age and first duly sworn, deposes and says as
follows:
1. That Tomas Nels Nelson, also known as Tom N. Nelson, the decedent mentioned in the
attached certified copy of the certificate of death, is the same person as Tom N. Nelson
named as one of the parties in that certain Quitclaim Deed dated October 18, 2002, executed
by Deborah A. Lynch to Tom N. Nelson and Deborah A. Lynch as joint tenants, recorded on
October 23, 2002, in Book 502PR at Page 540, 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 I am the same Deborah A. Lynch mentioned in the above referenced 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 Tom
N. Nelson, his previous estate in the property was terminated.
3. That the certified copy of the certificate of death indicates that Thomas Nels Nelson, also
known as Tom N. Nelson died on March 8, 2012 in the Town of LaBarge, County of
Lincoln, State of Wyoming.
Dated this U r7 day of April, 2012.
STATE OF WYOMING
COUNTY OF LINCOLN
This Affidavit of Survivorship was
Lynch, this 7,� t' day of April, 2012.
Lot 20 of the Viola Subdivision Phase No. 1, Lincoln County,
Wyoming as described on the official plat thereof.
ss.
DMIA.A. tsER ctilARMILL
MOM t c S OF
LKOt9 v Ill'YOUNG
NY CONASCo$ EXPIRES
AFFIDAVIT OF SURVIVORSHIP
c
DEBORAH A. LYNCH
00196
RECEIVED 4/25/2012 at 3:37 PM
RECEIVING 964270
BOOK: 785 PAGE: 196
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
subscribed and sworn to before me by Deborah A.
A90. /gi n /.1
NOTARY PUBLIC
My Commission Expires: ,.,3/,7,00015
ri
's rl'7l:4t1uaas
Decedent:
Name:
Gender:
Date of Birth:
Place of Birth:
'Residence:
Marital Status:
Armed Forces:
Name of Father:
Name of Mother:
Informant:
Other Significant
Conditions:
Manner of Death:
Certifier:
Type:
Name:
Address:
Date Filed:
622268
STATE OF WYOMING
Thomas Ne.ls Nelson
Male
March 18, 1954
Date and Place of Death:
Date of Death: March 08, 2012
City of Death: La Barge
Location: 188 Big Springs Rd.
Additional Decedent Information:
Fukuoka, Japan
La Baroe, Wyoming
Divorced
No
Carl Ernest Nelson
Barbara Brown
Deborah Lynch
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.
(a) Acute respiratory failure
(b) Secondary to Aspiration Pneumonia
(c) From End Stage Multiple Sclerosis
Natural Death
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming.
'DATE IS S UED:Friday, April 06, 2012
This copy is not valid:itnless prepared on paper with an engraved border.
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
Physician
Shannon Evans, D.O.
821 E 18th St, Cheyenne, Wyoming, 82001
April 05, 2012
State File Number:
Social Security Number:
Age at the Time of Death:
County of Death:
Relationship:
Time of Death:
LYr1%?S 2 2 1 &K�C.
James McBride
Deputy State Registrar
57 years
Lincoln
Girlfriend
Interval:
18:05 (Actual)
'I
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CERTIFICATION OF VITAL RECORD