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ss.
COUNTY OF LINCOLN
RECEIVED 7101.___? at 9:57 AM
RECEIVING 965731
BOOK: 790 PAGE: 191
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
001.91
Grace Ellen Merritt of PO Box 458, Thayne, WY 83127, upon her oath deposes and says:
1. That Marvin LaMar Merritt, the decedent mentioned in the attached certified copy of
State of Wyoming Certificate of Death, is the same person as MARVIN LAMAR MERRITT named
as one of the grantees in that certain Decree Quieting Title dated the 18th day of July, 1994,
entered by the Honorable John D. Troughton, District Judge, in the District Court of the Third
Judicial District in and for the County of Lincoln, State of Wyoming, grantor, and recorded July 18,
1994, in Book 354 PR, page 280, of the Official Records of Lincoln County, Wyoming, covering the
following described real property located in Lincoln County, Wyoming, to -wit:
Beginning at a point which is 208 feet north and 1 rod east of the Southwest Corner
of the SW1 /4SE1/4, Section 20, T34N, R118W, 6th P.M., Lincoln County, Wyoming,
and running thence North parallel to the West boundary line of said SW1 /4SE1/4,
1,112 feet, more or Tess, to the North boundary line of said SW1 /4SE1/4; thence
West along said North boundary line, 1 rod, more or Tess, to the Northwest corner of
said SW1 /4SE1/4; thence South along said West boundary line, 1,112 feet, more or
less, to a point 1 rod east, more or less, from the point of beginning; thence East
parallel to the South boundary line of said SW1 /4SE1/4, 1 rod, more or Tess, to the
point of beginning.
2. That the undersigned affiant is the same identical person as Grace Ellen Merritt
named as one of the grantees in the above- described Decree Quieting Title, that MARVIN LAMAR
MERRITT and she were husband and wife at the time of the execution and recording of the Decree
Quieting Title described above, and that as the surviving cotenant and spouse of MARVIN LAMAR
MERRITT, named in said conveyance, the undersigned, Grace Ellen Merritt, became on August 29,
2004, the date of the death of the aforementioned decedent, the owner of the lands or the owner of
any interest of MARVIN LAMAR MERRITT, in the lands described in the foregoing, subject to any
then existing liens and encumbrances.
DATED as of the 3rd day of May, 2012.
Witness my hand and official seal.
GERALD L GOULDING NOTARY PUBLIC
County of
Lincoln
State of
Wyoming
My Commission Expires May 2, 2015
My commission expires: May 2, 2015.
2
Grace Ellen Merritt
00192
Subscribed and sworn to by Grace Ellen Merritt before me this /97 day of July, 2012.
NOTARY PUBJIC
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1. DECEDENTS LEGAL NAME (Include AKNo II any) (First. Middle, Last)
MARVIN LA MERRITT
2. SEX
MALE
3. DATE OF DEATH (Ma/Day/Yr) (Spell Month)
AUGUSD 29, 20
4. SOCIAL SECURITY NUMBER
5a. Ade Lasialrawlay
(Y
80
5b. UNDER 5 YEAR,
50.1)140
R 1 DAY
6. DATE OF BIRTH (Mo/Oy/Yr)
JULY 14, 1924
Months
De 5
Honig'
midutai
7a. PLACE OF DEATH (Vied ONY 0 5
IF DEATH OCCURRED INA HOSPITAL
0 Inpaltal 0 ER) Oulpalien1 0 DOA
IF DEATH OCCURRED SOMEWHERE OTHER IRAN AHOSPITAL
0 HOSpice Feeley 0 Rinsing Hans /Log Tenn caroFealty arlaceitenrs Horne 0 Olher
eerily)
'TR FACILITY NAME (II notinahlutla, eiveRreet and nurna)
3312 COUNTY ROAD 122
17,-9777:7V4H. OR kMATIGN OF DEATH
,540•:72., 1,0, y,
5d ,COUNTY 01' DEATH
LINCOLN
B. BIRTHPLACE (CIN ad aisle or foreign country)
BEDFORD, WYOMING
9.11ARITAC'UTATUS
ib. SURVIVING SPOUSE (11 wile, give name prIo/ to brat marriage)
RACE.: ELLEN FLUCKIGER
11 sten 114 LIS.' '5.
ARMED FORCES?
ox 0 No
72a. RESIDENCE 4STAT
k
WYOMNa) .0'
)c
12.INC01:1■1,"
126:6•TY, TOINNOTILMATION
'ORD'''
3312 COUNTY ROAD., 122...
la. ZIR6o
8311'
J21.risiosciriCiiirrs?
13. FATHER'S NAME (FIrol, Middle, *9, 5 i'
GEORGE RERE,R..," 4ERRITT
14.1.10THERU NAME PRIOR TO FIRST MARRIAGE (Firo Lan),"
ETIIEL.;SPACIWkli
152.INFORMANTB Iamb
GRACE MERRIT;T:
1551 RELK/IONSHIPTOOECEDENT
SPOUSE
'56c. MARiNOVDRES, b (Stroma Chi, Stat, Elp opiip)'''.
3312 CO YROAtI, 122 BE1)F WYOMING 83112
16. METHOD 06 DISPOS)IIOR6
R1 rial
Bu D06911011 0 R Hovel horn Wyerding
0 Cremation 0 EnUbment 0 Other
178, PLACE OF DISPOSITION INem of
7 5, 55'
BEDFORD CEMETERY
4
171). LOCATION -000117pWNANDSTATE
BEDFORW' V
1 flit. 0 RAL CENSEE
Sr
605 Llupusuuo..,,
814=428
taa,..unma OF FACILITY: li
1-
-8b51AB' NoFriJARy
18174506161ET OF FAGI
44 EAST it TH' AVE'. ,AFTO.N.
M
al CC
LLI
g
m 0
ea
g
I,
20 AC AL E 0'DEATH
040
21. DATE P,RONODNCEDDEAD ihko/Dapp p
AUGUST 29f; 2.004
22 timero r
0409' 9 •c
AVFQMONERCONIACTED?
24. MAT I. Enter the 44 l-, eiseases, intone dr emplicatlan thafdlrectlicaused thelleatlipRNTnler
east respfteaw arail vebtncUlar lathallon wahouiefdlina swaliology. DO NOTABBREVIATE.
'"`""r -2, i i
IMMEDIATE CAUSE /Fnal caseate or 1...4 a a a II
°POW.. TOMB 005056) OURTOlfor a 3 caiequeTnen
Sequentially list condllionldanyT .5 'V 7 i
leading lo !he cause Mal on Jona a. i
lenninal tants such as cease f 14"
EMN,baly one caua on Me: Add additional fines
;1,
..li tell 1 -5 4 ./.5 .5
Apprpdmals inlerval:
(disease or Innoylhat InIliated lhe puRTOr as aconsequence off:
DUE TO(or,es acor10466146 Or l ,i '5 5 9•
i
PART i Oslo pther significant condilions'abibim lodimin but nol resullinbin the .1*iyjno .110449
V. WAU,AN AUTOPY.
PERFORMED?
OYES li
26. WERE AUTOPSY FINDINGS AVAILABLE To CONIFLETE THE CALISE OF DEATH?
O YES Mk)
2T oiroa,Acco uSE CONTRISUTE TO DEATH?
O YES MO 0 PROBABLY CI unkNowN
28.,1F.FEMALE AGED 10,54
0 85* pregnant Minh past year 0 8116 pregnant, but pregnant 43 days lo 1 year before dealh
0 Pregnant at las of death 0 Unknown it moment within 50 626 Tar
:•0 No7pf anal. but MegnanEwithin 42 days of death
29 MANNER OF DEATH'
3 8210,21 050,560642
04,500111 0 Fading investigation
0 Suicide' OCould nol be aftwniinad*
30 DATE OF INJURY (Mo/DayN)
31. 71516 06 INJURY l l
5
32 PLACE OF INJURY (Decedent's hdra, m m ai Ion al 6,85* 10)
3D5NJURY AT WORK?
0580 0 NO
34. LOCATION OF INJURY (Street and number, City or Town. Slate)
35, IF TRANSPORTATION ACCIDENT. SPECIFY
0 Driver Operator.. 0 Pedestrian
0 Passenger 00510, (51..4?)'
36. DESCRIBE liOiv wutaw oc0FIRED.ANO)E TRANSPORTAYON INJURY. THE TYPE(S) OE VEHICLE(5) INVOLVED (Ainornobee, plaup, rnolorcych6ATY, bicycle, etc.) I
370. CERTIFIER (Cheek only one)
FFiyiiciAN IIR bat oirny i r l i w l e d g e 0.01515100094 a1 the Ilme;•date and pRa, and RN to the cause(s)ad manner Haled.
CORONEFI. On 50 5. )71 evanaation en0/0 5 ve. tlenIPM Raton. bbeth ciecuad adhe me. date end Mace, and due to the eausom and
A
Signature el Certifier 4.•10 0 _IP.' Ad
mannastated.
5 1110
37b. DATE CERTIFIED (Mo/Da
.s 0 oi_....
'6
374.4AME.117 140ADDRESS OF CERTIFIER (Type 02 ant)
ti. t. PERKES MD' 110 HOS.? ITA LAME' AFTON', WYOMI 133110
39,. 911019711 l. 5
3135. DATE RECEP/E0 BY REGISTRAR (Ma/day/TN'
r C
CERTIFICATION VITAL RECORD
LOCALFILE NUMI3EFI
DEPARTMENT OF HEALTH
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
This is a true and exact reproduction of the document on file in the office of Vital
Records Services, Cheyenne, Morning.
SEP 3 20
DATE ISSUED:'
STATE FILE NUMBER
;r
Lucinda McCaffrey
Deputy State Registrar
This copy is valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar.
FIE
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