HomeMy WebLinkAbout965872Affidavit of Survivorship
I, Grover W. Nielsen, being of lawful age and duly sworn according to law, upon
my oath, depose and state:
That under the date of September 15, 2000, for valuable consideration, Leisure
Valley, Inc., by deed of that date, which deed was duly filed of record in the Office of the
Lincoln County Clerk, on January 8, 2001, in Book 458PR, Page 032, conveyed to Grover
W. Nielsen and Fern S. Nielsen as joint tenants, the following described land, in the
County of Lincoln, State of Wyoming, to -wit:
Lot 273 of Star Valley Ranch RV Park Plat One as platted and recorded in the Official
Records of Lincoln County, Wyoming
That by reason of said conveyance aforesaid, the said Grover W. Nielsen and Fern
S. Nielsen, 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
Fern S. Nielsen, also known as Fern Stock Nielsen, on the 7th day of June, 2007. That by
reason of and upon the death of Fern S. Nielsen, title in the above described real
property vested in Grover W. Nielsen
Affiant avers and certifies that Fern S. Nielsen, also known as Fern Stock Nielsen,
is the identical party named with Grover W. Nielsen in the aforementioned deed, whose
death terminated her 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 day of
State of U
ss.
County of A.A- 1
Subscribed and sworn to before me, a notary
State, by Grover W. Nielsen, thisay of
WITNESS my hand and official seal.
My Commission Expires:
RECEIVED 8/1/2012 at 2:16 PM
RECEIVING 965872
BOOK: 790 PAGE: 586
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
1
2012.
Grover W. Nielsen
058
ubc in and for said County and
2012.
NANCY J BROWN NOT BUC
County of ►k M�w State of
Uncoln WyomIng
My Commission Expires June 25.2014
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Requested By: Grover William Nielson
Wendy John, Graham County Recorder
02-24-2012 01:11 PM Recordino Fee $9.00
RECORDED AT THE REQUEST OF:
RETURN TO:
Grover William Nielsen
GRAHAM COUNTY RECORDER
921 THATCHER BLVD.
SAFFORD, AZ. 85546
Death Certificate
CAPTION HEADING
OF ARIZONA mo
'ONTYOF GRAHAM
D cDP -|NQTRuMEN|
Decedent:
Name:
Gender:.
Date of Birth:
Date and Place of Death:
Date of Death: June 07, 2007
City of Death: Afton
Additional Decedent. information
Place of Birth: Tucsdn,: Arizona:.
Residence: Star Valley Ranch, WyOrni
Marital Status: Married
Name of Father: Francis rock y
Maiden Name; of Maher. Poreri,e M Caa�i~a
Informant: Grover Willi*
Disposition:
Method of disposition:
Place of Disposition:
Cause of Death:;
The immediate c is listed an :t gtat liefA/kored *,y ritut1ddrfying causes.
(a) Carclio Renal Failure, Progressive
(b
b Age, A #herosclerosis:
Other Significant Conditions Diabetes;:'
345167
Orson D. Parkes; M,D.
110. Hospital:i:n; •Afton Wjtamitigi,.
June 13, 2007
This is a true certification of the document on file in the office of Udel
Records Services/Cheyenne, Wyoming.
DATE ISSUED:
This copy is nut valid unless pnpunad on paper with an engraved bonier.
June 21, 2007
DEPARTMENT OF HEALTH
State File Number: 2007 001729
Social.. Security Number;
Age at the Tints of Death: 84 years
vir>�.qua+�;. Graver William Nielsen
2012- 00887 02 -24 -2012 0.1:11 PM Page 2 of 2
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