HomeMy WebLinkAbout966075STATE OF WYOMING
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COUNTY OF LINCOLN
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RECEIVED 8/10/2012 at 10:31 AM
RECEIVING 966075
BOOK: 791 PAGE: 217
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
I, MARISELA HUMPHREYS, being first duly sworn upon my oath, depose and
1. That I am of adult age, a resident of Etna, Lincoln County, Wyoming, and
the Affiant herein.
2. That by virtue of conveyances which are recorded in the office of the
County Clerk, Lincoln County, Wyoming, in Book 646 Page 338, Robert C. Humphreys
and Marisela Humphreys, Husband and Wife, are the record owners of the following
described property:
Prater Canyon Unit 2 Lot 55,
Prater Canyon Unit 1 Lot 84.
TOGETHER WITH and SUBJECT TO: All Easements, Exceptions,
Reservations, Restrictions, Right -of Way and Improvements of sight and
or record.
3. That by virtue of conveyances which are recorded in the office of the
County Clerk, Lincoln County, Wyoming, in Book 495 Page 364, Robert Clark
Humphreys is the record owner of the following described property:
All of Lot 5 of the Humphreys Family Estate of record in the Office of the
Clerk of Lincoln County.
ENCOMPASSING and area of 2.06 acres, more or less;
All in accordance with the plat prepared to be filed in the Office of the
Clerk of Lincoln County titled, "HUMPHREYS FAMILY ESTATES
WITHIN THE E1 /2SE1 /4 OF SECTION 24 T35N R 119W LINCOLN
COUNTY WYOMING," dated 13 May 2002, as revised.
Welty Probate
Affidavit of Survivcrship
1 of 1
00217
TOGETHER WITH and SUBJECT TO: All Easements, Exceptions,
Restrictions, Reservations, Rights, Rights -of -Way, and Improvement of
sight and or record.
4. That by virtue of conveyances which are recorded in the office of the
County Clerk, Lincoln County, Wyoming, in Bock 342PR Page 236, Robert C.
Humphreys is the record owner of the following described property:
NW1 /4SW1/4, Section 23, T35N, R119W, 6th P.M., Lincoln County,
Wyoming, excepting therefrom: Beginning at the Southwest Corner of the
NW1 /4SW1 /4 of Section 23, T35N, R119W, 6th P.M., Wyoming, and
running thence North 10 rods, thence East 24.5 rods, thence South 10 rods,
thence West 24.5 rods, more or less, to the point of beginning.
ALSO EXCEPTING THEREFROM: Beginning at the Southwest corner
of NW1 /4SW1/4; thence North 609 feet to a point; thence East 200 feet;
thence North 400 feet; thence West 200 feet; thence South 400 feet to the
point of beginning.
Subject to reservations and restrictions contained in the United States
Patent and to easements and rights -of -way of record or in use.
Together with all improvements and appurtenances thereon.
5. Said Robert Clark Humphreys died on the 16th day of June, 2012, at
Bannock County, Idaho, and a copy of the official certificate of his death, certified to as
true and correct by the public authority in which the original of said certificate is a matter
of record, is attached hereto as Exhibit "A
6. By reason of the death of said Robert Clark Humphreys, and by reason of
W.S. 2 -9 -102, his interest and title in said warranty deeds has terminated and title to the
real property conveyed thereby has vested in Marisela Humphreys.
Welty Probate
Affidavit of Survivorship
2 of 2
q n p 6 ..t
0 1 y
FURTHER AFFIANT SAYETH NOT.
DATED this &day of August, 2012.
SUBS IBED AND SWORN to and acknowledged before me, a Notarial
Officer, this day of August, 2012, by MARISELA HUMPHREYS.
WITNESS my hand and official seal.
TRACY MATTHEWS NOTARY PUBLIC
County of
Lincoln
State of
Wyoming
M Commission Expires September 26, 2013
My Commission Expires:
No i r' .1 Officer
Welty Probate
Affidavit of Survivorship
3 of 3
ARISELA H`' MP REYS
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1.DECEDENT'S LEGAL NAME.(Include
ROBERT CLARK HUMPHREYS
AGE -La t Bidhtlay ;4bUNDER
62 Months
(Ye rs)
7a:REs)OENCE -STATE OR'
WYOMING.
7d. STREET AND NUMBER
105762 HIGHWAY 89
AKA'@ 11 any) (First-Middle,
7 YEAR 4C. UNDER
1
Days Hours ;Minutes
COUNTRY T7b
DEATH
Wdowag ❑Divorced
I
NAME(Flrsl, Mitldle lasl..5ulrx)
HU MPHERYS.
MAIDEN NAME (First,
print)
Last; Su.. x) 2. SEX 1 3 SOCIACSECURITY NUMBER
1 MALE
1 DAY 5 OATS OF BIRTH (MoIDa 6 BIRTHPLCE;(
AC ty d Stale
an,'T rri1 ry, or Fora gn Country
'05/01/1950. AFTON, WYOMING
CO ;7e. C I7Y.OR TOWN
ETNA
7e.Aitrio i ll ZIP.C66i I7g:INS1oECI7Y.
8 118 LIMITS?
19. SURVIVINGsPO NAME (Irwl give ol na
B. MARITAL STATUS AT TIME OF
Married ❑.Married; but separated
Never.married ❑unknown MARISELA ISABEL MARTINEZ
i 11b. BIRTHPLACE (Stale, Territory, or Forei Count
;`WYOMING
.le ry• or F.b. m9 .Cg eidM.
M;ddie, Lesl, sulf 12b. BIRTHPLACE sl Tr
ate e
WYOMING
ION p
13b. RELATIONSHIP TO DECEDENT 1J MAILING ADDRESS Slr a nd Numbe Cdy SI le Z( Cod
SPOUSE P.O. BOX 5176 ETNA, WY 83118
t0. EVER IN U.S. 11 a. FATHER'S
ARMED I
F D EAN G.
Yei 5xd. MOTHER' S:
60N° 1 NEVA CLARK
NAME T
type o
M H
f ..t
ce:
0
14. METHOD Of DISPOSI 15 PLAC OF DISPOSIT
Burial Cremation I crei other
❑:Donation ❑'Entombment ETNA CEMETERY
Removal nom Idaho
olher(Speedy/ I ETNA, WYOMING183.118
ION (Nam e.a nd a of cemetery r 1B. NAME AND CoMp�ET� A DDRESS OF FUN ERAL F ACILITY
place)::
HAWKER FUNERAL;HOME
132 SOUTH'.SHILLING "AVENUE
BLACKFOOT, IDAHO 83221
PERSON ACTING AS SUCH ':)Tb. L NUMBER (Ol licen WA
see)' 10S.CORONER CONTACTED
l• TO CAUSE 00 DEATH?
I M0748 Yes 'MN'.
173, SIGNATURE OF FUNERAL SERVICE LICENSEE OR
I': ELECTRONICALLY FILED: KEVIN T. DIETRICH
'1
,IM
2
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p
P.'.
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b
y
N
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o :D
U
le
k .35.
re
W
:1$
piinatrire
193. IF -0EATNOCCURREQ IN A
21Inpatient 2 ❑ER /OUlpl l'S❑00A
HOSPIT 19b.IF D EATR
4 ❑Hop
number)
give sheet and number)
CENTER
PL (1g- 22)-
OCCURR SOMEWHERE OTHER THAN A HOSPITAL:
*MY ,g 000ro&o g term care facility e❑Oeeedenl's home 7❑. 01her (Specify)
'20,FACILITYNAME()f lacdity,
ti
PORTNEUF MEDICAL
LOCATION
21.-CITY, TOWN, YOWN, OR LOCATION OF DEATH, AND Zip CODE CgUNT
2T OUNTY OF
POCATELLO, ID 83201 BANNOCK
23. DATE OF DEATH (Mo/Day/Yr) (Spell month)
June 16, 2012
24. TIME OF DEATH 125. GATE PRONOUNCED DEAD,(MO/Day/Yr) (S month) 1 20 TIME PRONOUNCED:DEAD
(2460 (241r)
17:15 June 16, 2012
1715-
PART 1. .Enter the chain of evenl2 diseases
Injuries, or complications
fibrIllalion wdhoul showing
DUE TO(ores
DUE TO (or as
DUE TO (br abb
conlnbu(in0lo Eealh
30, IF FEMALE (A d
Not pregnant vdtmn
Pregnant at time
Not pregnant but
within 42days
27. CAUSE OF DEATH
that: directly caused the death. DO NOT enter terminal events such as cardiac Approximate Interval:
die apology. bO NOT ABBREVIATE. Enter only.one cau n a Iklline:: Onset to Death
o
DE ACUTE
a consequence oq'
a consequence oh:
arms', respiratory arrest; or venlrloular
MED(Final.'
dul cnn C ddion USE (Fine SUDDEN`CARDIAC
a.
resulting In death)
Sequentially list conditions. b UNKNOWN
if any; leading lo, the cause
listed orr Ilse a: Enter the
UNDERLYING CAUSE. b
LAST(d'ueasa :e injury:
Mat ln0raledNe events:
resulgn•n death)
PART Ir. Ent r olhersionificenl conditions
TOB UE S
29O1D ACCO
CONTRIBUTE TO DEATH?
Yes Probably.
No Unknown.
consequence ?Ig
but not resuilNg n 1Ha undedymg cause iNenin Pad I T70a: WAS AN AUTOPSY 2B6 WERE AUTOP$Y'FINOIGS
PERFORMED? AVAILABLE TO COMPLETE
1054 :2THECAUSEOF.DEATH1-
R Yes N_b': Yes No'
past year Not pregnant. but pregnant 43 days
tot year before death J fit', MANNER OF DEATH
o(death Nalu al
pregnant Unknown if pregnant within the past i Accident Pending leVesliga1lon
of death year. Suicide Could not be determined
32. DATE OF INJURY'(Mo/Day/Yr)
(Spell month)
33. TIME OFINJURY 34: PLACE OF.INJURY {Decedent's home, farm, street, censiruelien Ole, 1.35. INJURY AT WORK?
■24hr) nursing ha restaurant forest. etc)
Stale •Cit(l Town or Count' .Zip Code
LOCATION OF INJURY:
Street and Number or Location
Apanmenl NUMger
IC T 6
37., SPE HOW OCCURRED. IF CU PIE0 aATi STATE THE TYPES(5) OF VEHICLE( (Aulamob le pickup, olo cycle ;AN bicycle. etc.)
'CIFY. IFY. WHICIC VEHICLE OCCUPIED H VEHICLE DECEDENT OCCUPIED 0 applicable le
TRANSPORTATION 300 •WAS DECEDENT: ❑:Dmer/Opartor Passen 30b. WHAT SAFETYDEVICEE DECEOENT.US
.'IURY ONLY. Pe
NJ
Pedestrian Olher(Sp Seet beg: Child sate) neat
y 0H01m t ;,0:An 6ag.. ❑None Unknown
39a. CERTIFIER (Check only one, based on official capacity
PHYSICIAN 9 PHYSICIAN ASSISTANT
To the best of my knowledge, death occurred at the time,
CORONER
-:00 (he basis of 0Xaminalion and /or investigation. in.my opinion;
end:manner slated.
and Tilleol Certir r/ DAVID'M GONZALEZ,
39d. NAME, ADDRESS, AND ZIP CODE OF CERTIFIER (Tyne
DAVID M. GONZALEZ, 777 HOSPITAL
for Itds cent0cale) LICENSE NUMBER
0 ADVANCED PRACTICE PROFESSIONAL NURSE 1 I' ...M-09795
date, and place, and due to the net cause(symannerslated. 1
1 39c. DATE SIGNED
death occurred at the lime, dale, and place. and due to the cause(s)
6 25 2012
MA, MM .DD YYYY
or pOn7
WAY.POCATELLO, ID.83201
40..:REGISTRAR'S SIGNATURE
(07.14A
40b DATE SIGNED
..46. L R 35
MM ::UO YYYY
l
CERTIFICATION OF VITAL RECORD
►'3
TYPE OR.
PRINT1N'.
PERMANENT
BLACK INK
00 NOTUSE
'FELT 71P FEN
FOR
INSTRUCnONs
SEE
HANDBOOKS
INFORMANT
DISPOSITION
PLACE OF
DEATH
DATE OF
DEATH
CAUSE OF
DEATH
ITEMS 3235
TO DE USED
FOR EXTERNAL
CAUSES ONLY
(CORONER)
DUE TO OTNER
1HAN NATURAL
CAUSES
:THB CORONER
COMPLETE AND'
SIGs THE
CERTIFICATE
PBNCO(9007 /10
STATE OF IDAHO
IDAHO DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
State :of.Idaho
CERTIFICATE OF DEATH
a Mwiosui, '4Wle a umniwni:OEe veRlcFOiIRfe0MEV1,Tn'o"ERS>aNii er/ NOweu:ene g
I suar.rw.ua coos L0.ca4Re
This is a true and correct reproduction of the document officially registered and placed
on file with the IDAHO BUREAU OF VITAL RECORDS AND 6HEALTH :STATISTICS,
AT SE: �\p p
-�O PfiRP�_,� 1t1 /yl
'0 3 DATE ISSUE eZ/Y�.� o7J� nCrcftl ("Vt14
i This copy. not d unless., prepared on engraved border JAMES B AYDELOTTE
displaying state seal and .5ignature of- Registrar'':' STATB.k GISTRAIt
RMY Y YIFYI1vs'1 �Y�•!v ,rI
VA 1
VA VAL
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111111.7M•DIUGLIII_ \i[1.