HomeMy WebLinkAbout964290Recording Requested By:
Susan K. Johnson, Surviving Trustee
10025 Rolling Glen Court
Las Vegas, NV 89117
After Recording Mail To:
uDeed, LLC 55743
9041 South Pecos Road, Suite 3900
Henderson, NV 89074
Mail Tax Statements To:
Susan K. Johnson, Surviving Trustee
10025 Rolling Glen Court
Las Vegas, NV 89117
T35 R118 S30 PT. NENW 4, 10 ACRES
00259
RECEIVED 4/26/2012 at 11:17 AM
RECEIVING 964290
BOOK: 785 PAGE: 259
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Assessor's Parcel No.: 35183020000200
AFFIDAVIT OF SURVIVING TRUSTEE
TITLE OF DOCUMENT
I, Susan K. Johnson, the undersigned, affirm under penalty of perjury under the laws of the
State of Wyoming that the following is true and correct:
(1) By instrument dated July 14, 1998, Charley R. Johnson and Susan K. Johnson
executed The C.R. Johnson Trust.
(2) Said trust appointed me to serve as Surviving Trustee upon the death or incapacity of
Charley R. Johnson.
(3) Charley R. Johnson died on November 22, 2010 at Las Vegas, Nevada, a resident of
Clark County, Nevada pursuant to the attached certified copy of the Certificate of Death
and is the same person as said Charley R. Johnson.
(4) Pursuant to the terms of the Trust, I have assumed the responsibilities of Surviving
Trustee.
(5) The following described real property is part of the trust estate:
COMMONLY known as: Prater Canyon Drive, Star Valley Ranch, Wyoming
(6) No other person has a right to the interest of the Trust in the described property.
(7) The described property shall be transferred to Susan K. Johnson as Surviving Trustee.
WITNESS TRUSTEE'S hand this 6 day of
Susan K. Johnson, Surviving Trustee
STATE OF e J& J. o.
COUNTY OF CAA, k ss
20
Signed and sworn to (or affirmed) before me on (o±lday of A �r i
20 12 by Susan K. Johnson, Surviving Trustee.
NOTARY STAMP /SEAL
Notary Public State of Nevada
COUNTY OF CLARK
JANET HURT
No. 94.14604 *Appointment Expires Match 21, 2014
Witness my hand and official seal
Signature of Acknowledging Officer
-3. avl.tz.1 Cru.
Printed Name of Acknowledging Officer
Title (Rank) of Acknowledging Officer
MY Commission Expires: 3 27 1 4
00260
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15a. RESIDENCE STATE 15b, COUNTY
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Clark
PARE TS 16. FATHER NAME (First Middle Las Suffix) 17. MOTHER NAME (First Middle Last Suffix)
20c. NAME ADDRESS OF FACILITY
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SHRADEF�
a (:ORMANT NAME (j1 i f Q �I' I III 18b. MAILING-ADDRESS (Street oeR F D. No City or Town, Stale Zi
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1 Sus- I l II6 I I, Ill 00 5 Rollfng ten Ct. Las Vegas, al g9 7
19a BURIAL, CREMATION, eVAL, 4 R (Specify 19b CEMETERY OR CREMATORY NAME 19c. LOCATION City or Town State
DISPOSITION Burial Southern Nevada Veterans Memorial Cemetery Boulder City Nevada 89005
SIGNATURE 20a. FUNERAL DIRECTOR SIGNATURE (Or Person Acting as Such) 20b. FUNERAL
RICHARD C BOBO DIRECTOR LICENSE Bunkers Mortuary
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TRADE CALL TRADE GALL -NAME AND DDRE THENTICATE 1111111I, 69 '111111 VI' 1111111111,1 11 l l, l ll'� 5 N Las Vegas Blvd L llll l V NI 11111 -0 0 due to the cause(s) statM(S grTatucs& Titler SIGNATURE AUTHENTICATED 1� time lh b date nd lb place lace and due to the i s �1 I III n 1 1 I l w gills 1, i i O examination and /or l- i na q
sf CHRISTOPHER CHOI MD a o
CERTIFIER E a 21b. DATE SIGNED (Mo /Day/Yr) 21c -HOUR OF DEATH E n 22b. DATE SIGNED (Mo /Day/Yr)
fi z November 23, 2010 10 :52 Z
p 21d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER o 0 22d. PRONOUNCED DEAD (Mo /DaylYr) 22e. PRONOUNCED DEAD AT (Hour)
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I V E A ADDRES IW" I jl i y 4DING PHYSICIAN 10105 Banburry Vegas NV 89144
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1 N IIETT HARRINGTON 24b DATERECEIVED BY REGISTRAR 24c D1_i b19E4�E5 "COMIOIUNTCABLE DISEASE
(Mo/Day/Yr) November 23, 2010 YES No Ei
3c. SPITA
and number
6. Hispanic Origin? Specify
No Non Hispanic
SIGNATURE AUTHENTICATED
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OR OTHER INSTITUTIOName(If not_ either,=give'street
10025 Rolling Glen Ct
25. IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c).)
PARTI (a) Multiple myeloma
PART it OTHER SIGNIFICANT CONDITIONS- Conditions con ributing to death but not resulting in the underlying cause given in Part 1.
11144' 111
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E SUICIDE, HOM., U r t 7aTE If t FY Ody 28c. HOUR oe 28d ,ERESCRIBE FLOW IN.IURY OCCURRED
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28e INJURY AT WORK (Sped( y 28f PLACE OF NJURY- At home, farm, street, factory; office 28g. LOCATION
Yes or No) building, etc. (Specify)
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(d)
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DUE TO, OR AS A CONSEQUENCE OF:
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115c, CITY, TOWN OR LOCA
Las Vegas
15d. STREET AND NUMBER
STATE REGISTRAR
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7a. AGE -Last
birthday (Years)
78
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10025 Rolling Glen Ct
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7b. UNDER 1 YEAR 7c. UNDER 1 DAY
MOS I'DAYS HOURS I MINS
II
Registrar of Vit
By:
Date Issued:
Pi
111111111
CERTIFICATE OF DEATH 2010017509
11111
STATE FILE NUMBER_
DATEOF DEATH (Mo /Day/Year) Sa Z IUNP =O EA I:
N ovember 22, 20
3e.lf Hosp. orinst. indi-D07R1Emer.:Rm.
Inpatient(Specify)
Home
8 DATE OF BIRTH (Mo /Day/Yr)
December 12, 1931
22c HOUR OF DEATH
mi
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4. SEX
orces? Yes
15e. NSIDE CITY
LIMITS (Specify. Yes
or No) Yes
Interval between onset and death
Interval between onset and death
26. AUTOPSY 27. WAS CASE REFERRED
(Specify Yes pr No) O OOROSER (Specify Yes
Ito, s,i NOS Yes
STREET OR R.F.D. Nt CITY OR TOWN STATE
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DEC 2 0 2010
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Male
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"CERTIFIED TO BE TRUE AND CORRECT COPY OF THE DOCUMENT ON FILE WITH THE REGISTRAR OF VITAL STATISTICS.
STATE OF NEVADA." This copy was issued by the Southern Nevada Health District from S certified documents as authorized by the
State_Board of Healthpursuant to TRS --4Q (IIII' tllll!' ll IIII
lll� X 1 1 I I
Iry I I Lawrence
RIOT VALID WITF'IA'HII2IS
SEAL OF THE SOUTHERN NEVADA
HEALTH DISTRICT
ladow Lane P.O.x 3Lasega� NEtada9127 702- 759- iTBOa1liB -�1+