HomeMy WebLinkAbout965537RECORDING REQUESTED BY
JONES WALDO HOLBROOK MCDONOUGH PC
SEND TAX NOTICE TO:
DELSA T. BARBER
2252 South 1000 West
Syracuse, UT 84075
AFTER RECORDING RETURN TO:
JONES WALDO ATTN: I.JB
170 South Main Street, Suite 1500
Salt Lake City, Utah 84101
STATE OF UTAH
COUNTY OF Util
1038315.1
‘0! Pudic
Oct. ib, 2012
E ;u .i∎ Sicil t 5713407
SS
AFFIDAVIT OF SURVIVING TRUSTEE
DELSA T. BARBER, being first duly sworn, deposes and says:
1. Affiant is the surviving spouse of REX C. BARBER, who died on December 20,
2002, and who is named in that particular Certificate of Death, File No. 06 -1052, a certified copy
of which is attached hereto and made a part hereof, and is also one of the initial Trustees and
Trustors under the REX C. BARBER FAMILY PROTECTION TRUST, dated February 27, 1997.
Affiant is presently eligible to act as the sole Trustee due to the death of her spouse, initial
Trustee and Trustor, REX C. BARBER, and hereby accepts the responsibility as sole Trustee.
2. Affiant knows the said REX C. BARBER, deceased, to be one and the same person
as who is named as joint grantee and as a Trustee of the Trust in that particular instrument
recorded as Entry Number 850308 in Book 411, Page 529, in the office of the Lincoln County
Recorder, and covering the following described property located in Lincoln County, Wyoming:
STAR VLLY RANCH UN 2 LOT 5
RECEIVED 7/13/2012 at 10:37 AM
RECEIVING 965537
BOOK: 789 PAGE: 400
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
SPACE ABOVE FOR RECORDER'S USE
PARCEL ID NUMBER:
DELSA T. BARBER, Surviving Trustee
The foregoing instrument was acknowledged before me this a Ina(' 6 0 2012,
by DELSA T. BARBER, Surviving Trustee, under the REX C. BARBER FAMILY ROTECTION TRUST,
dated February 27, 1997.
00400
n Fn STATE OF UTAH DEPARTMENT OF HEALTH
,11147 Smev e sA �DCALFILENDMBER- 06-1052
OF. DEATH
aM Ruka.
1, NAME OF DECEDENT FIRST MIDDLE. LAST 2SEX 13a. DATE OF DEATH (Mo.; Ogy Yr)36T'IME OFOEATH {24 M�iocNt
Rex BARBER Male December 20.:2002 429
4 DATE OF BIRT (MO., Day, Yr.) AGE Laol &nhday IF UN¢ER t YEAR 7F UNDER 2. 08S. 16, BIRTHPLACE (City
November 1Z I2 3 or Foreign Country-)., SOCtN. SECURFIV
moms L Uaya 1 MOWS minutes
II Syracuse, Utah COAtfderf_t1&0
ea. PLACE HOSPITAL (mho mdss ALL OTHER LOCATIONS. 96 NAME OF HOSPITAL NURSING HOME OR OTHER FACILITY
OF DEATH (if outside a faulty, give 0708) 0007000 d( k74000)
(check only 1 Inpalool 5. Nursing Hoe 6 Residence (ang)
one) 2 ER/Outpatient 3.000 i. Other (speon) Davis Hospital and Medical- tenter
6c. CITY, TOWN, OR LOCATION OF DEATH' 9d, COUNTY OF DEATH 9 SURVNING SPOUSE (d 0* 9 0,070.,, name)
Layton, Utah Davis Delsa Thurgood
DECEDENT 10 WAS DECEDENT 11. MARITAL STATUS 120. DECEDENTS USUAL OCCUPATION (Give loud o(,.ukdorre 120. KIND OF BUSINESS OR INDUSTRY
EVER IN THE U donng matt o(wonbrg fife. Oa NOTenfe('reD(Ld)
ARMED FORCES? 1. Never Monied 3. Wdo-aed
1. Yes 2. NO J(2 Horned 4. Divorced
Financia Officer_ :Manage Training Corp.
130. RESIDENCE STREET AND NUMBER 136 W
CITY, TON OR COMMUNITY 130. COUNTY 130, STAT
2252 Soutb_t West_ Syracuse Davis Utah
130UNSIOE CRY 137. ZIP CDOE 14, WAS DECEDENT OF HISPANIC ORIGIN? 1. Yes vv 2 No 15. RACE Black, Mite. e, Mn, 16, EDUCATION (sped(( only Mgheo!
LIMITS? (?!yes, Speedy) 1 Indian (tnbe maybe entered), grade completed) Elementary or
J- Japanese, tc (Boer.(() SemOWary (0.12) College (13.16
r 1: Yes 1. Mexican 2. Cuban a• dr_y_
2, No 3, Puerto Rican y,d Odler {Spats(()
84075 Whfite
17 FATHER'S NAME (First Mlddle. Las) _18. MAIOEN NAMf (.6441, La4D
PARENTS
Clyde C. Barber Matti-. W ket
79. NAME, u RELATIONSHIP AND MAILING ADDRESS OF INFORMANT
INFORMANT L
Delsa Barber /wifJ /12252 South 1000''West, Syracuse, Utah ;84075 Y
20. METHOD OF DISPOSITION yr 2107 DATE OF 216. PLACE OF DISPOSITION (nam Ot 0 cemetery, 21c. L0 ATION Cdy, n, Stale
r crematory, or Other place) w 'f k
1, Entombment- 2. Donation F-- 3. ONer
DISPOSITION 4, Burial. ,5 Crama)[o0� B.Aem'ov&
Dec. 24 2002= Syracuse C ity C S
22. SIGN RE OF FUNS ER LICENSEE 23 LICENSEE NUMBER 24 FUNERAL HOME (N ame and a4dleap)=
t 102929 Lindquist's Layton MortuaPy
25. DATE DECEASEO"4WAS LAST n(9
5,1f not 0a.4 by medical oo.m,nsr; 08817 reported to M E I.-Yes 2 No
ATTENDED BYC AN O yes. onleJ5medalarime reponad v 1 867 N o alr id d.
N O MM HR MO '"'DAY i WEAR d Layton, ta b 8
270. E TIFIER M„Nii 0 x s 70�
CERTIFYI
A tae, F N' ;y ��1} h 4-)n, r p}
1. 'W
NG.PHVSICIAN' T0 best of my knololedge''donlh 07407704 at the lane, dale, 0hd Place, and du to the 70408(9) a d mingle, as staled r G
CERTIFIER 2 MEDICALEXAMINER/LAW ENE EMENT OFFICIAL On -Iho haala of n e 4911(49 in ;death occunedat 6l lime, dale �Iace and due 10 0784
00 oojr() _nd manner as stale t 5
27b SIG R a TIT Q F CE �A 27c IOENSS NUM E 37tl DATESIG0 Mo If Oa y, (Nee
a r1
i s ZL� I ma
26, N AND YN
R ES OF PERSON-0 CERTIFIED THE E OF DEATH (Item 31) (TypePnnt) I
THE 1' h
Stephaflis Ilsenfy�M.D. 16607.41 Antelope Dave #2?v51, Laykt'o bit ah 84044
29. REGI TRAR'Si$tGNA t7' 1305' DATE'REGISTRAR NOTIFIEDtbF DEATHg1? DATE 7 11 0 (M0., Day; Yr.)
REGISTRAR 31. PART 1 ENTER TH a ISEASES, INJURIES OR C M ICAT ONS7HAT bA USED THE DEATH. M 00 07 E T ING, SUCHAS O CARDIAC: 2 I
NN (AC Approx'ma}e o0
OR RES• ORY ARREST SNO K ORHF "RT FAILURE LISTfONLY ONE -CAUSE ON EACHl(NE Be $sekenM
IMMEDIATE CAUSE (F')A_al-. p i ''.2451/10 h Wl7 F trdJ7'
disease or cor)ddlon reslll p� a
In death) V UE T AS CONS UENCE OF)
,if.. i 8 o t JCSI5 *fll
Sequentially 051 condthons d'' `a" DUE TO (OR AS A CONSEQUENCE -0F).
any, leading to immed'ate
cause. Enter UNDERLYING 0.
CAUSE (disease or in)u Y that F
058 ,10 (OR AS A CONSEQUENCE OF):
initialed events resulting m
f r
death) LAST .a c `'a
PART 11 OlherSgm7¢an7 conditions corte00ubft )c_dealh 32. (N YOUR OPINION. TOBACCO USE BY THE DECEDENT; 330 WAS AN AUTOP -331) WERE AUTOPSY
CAUSE OF 00Anblresullag in the 004 ,lyog use 9 I'"-44.1-'---' 0 PERFORMED? 1- FINDINGS AVAILAB
DEATH 1. Pm50Oq 00n0i5Ned to 0 cause 0i death .6 ._NON USER 1 PRIOR TO
I Vl a I i i S u C-1 P I' 2 Was the undertytnp cause of death 1 r i I CAUSEOEDEATH2
3. Did iO 9tnbule the cause o(0eam 6. UNKNOWN, I- 1. Yes 1 ya 2 N¢
4, Is unkr)nwm in relation l lolhw
auae of depth:
34. MANNER OF DEATH 350. OATS OF INJURY (MO„ Day, Yr.) 35b TIME OF INJURY 350 INJURY AT WORK? 350. PLACE 0? JURY home, 500,, street, (.dory,
(24 Hour Clock) 0 05018, budding, etc. (spec,(()
41 Natural 2. Accident ..1 1. Yes IJ 2. No I
3 W LOCATION (Street or rural route number, city or town, county and state.), 351 If motor vehicle ersWenl specify d decedent was driver,
3 Suicide Ji 4. Homicide pazsengerof peaestnan:-
15, Und lerrbi 1 8 Pending- I
5131-BVR I(.i'p red Invesllgol01 35g. DESCRIBEHOWINJ OCCURRED (enter sequence of Tls which re0ulkdFinjory NATURE OFINJURYsRO ldbe errMrer)rn7ferr(3))
Form 12;- 70rposn)y or
Rev: 12/98 Auidently
STATE FILE NUMBER
=R Garry
recitor/ HeaIth icer
County/Dlstrictilealth Department
555 YJ
ra p.. ,:q v
ONE
'of o r TH n h)
i i
.m. l i1,AxL el
:01
This is an exactreproduction of the document registered in the State Office ofllitagStatlstics,.
Security features of this official document include intaglIti Border, V R tmage._In'top cycloids,
Ultraviolet fibers and hologram image of the Utah State_Seal the words' Stale oMahn. itlis
documeiit display the date, seal and signature of the State Registrar=andthe County/District Health Officer.
afilfr
111111011011110 111 II
*06334
I Janice L Houston State Registrar