HomeMy WebLinkAbout966208File No.: 153100
STATE OF WYOMING
SS.
COUNTY OF LINCOLN
I, Chet Laval Larson, being of lawful age and first duly sworn according to law, upon my oath,
depose and state:
1. That I am of adult age, a resident of Evanston, Wyomin, and the Affiant herein.
2. That by virtue of the conveyances which are recorded in the office of the County Clerk for
Lincoln County, Wyoming, located at Kemmerer, Wyoming is recorded a Warranty Deed dated
the .g day of 400 O in Book 4 PR on page l G
conveys unto CJ-* c ee V 0-L the following described
property, to -wit:
3. That said Reba Larson on the a 3 day of aQ. c. 0 0 died and a copy
of the original certificate of death, certified to as true and correct by public authority in which the
original of said certificate is a matter of record, is attached hereto as Exhibit "A
4. That by reason of death of said Reba Larson by reason of 2 -9 -102 W.S. (1980), the decedents
interest and title in said conveyance has terminated and title to the real property conveyed
thereby has vested absolutely in u\-. continuously since
the death of the said decedent.
FURTHER AFFIANT SAYETH NOT.
Chet Laval Larson
al lia nce Title Escrow
PO Rox 1367
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AFFIDAVIT TERMINATING ESTATE
State of Wyoming)
)ss.
County of Lincoln)
The foregoing instrument was subscribed and sworn
August, 2012
Witness my hand and official seal.
L
Notary Public
My Commission Expires:
to me by Chet Laval Larson, this 2nd
LISA M. SPAULDING NOTARY PUBLIC
County of 4 1 State of
Lincoln L Wyoming
My Commission Expires July 18, 2015
006G'"
RECEIVED 8/15/2012 at 3:53 PM
RECEIVING 966208
BOOK: 791 PAGE: 667
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
day of
Date Filed
DECEDENT LEGAL NAME
REBA ER LARSON
NAME AND ADDRESS OF FUNERAL FACILITY
WEBB FUNERAL HOME, PRESTON, IDAHO
DATE OF INJURY
LOCATION WHERE INJURY OCCURRED
DESCRIPTION OF HOW INJURY OCCURRED
DECEMBER 27, 2010
STATE OF IDAHO
DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
CERTIFICATE OF DEATH
SIX SOCIAL SECURITY NUMBER AGE DATE OF BIRTH
FEMALE 87 YEARS NOVEMBER 19, 1923
BIRTHPLACE PLACE OF RESIDENCE
TURNERVILLE, WYOMING PRESTON, IDAHO
MARITAL STATUS AT TIME OF DEATH NA OF
l DATE OF DEATH TIME OF DEATH CITV.TOWN OR LOCATION OF DEATH COUNTY OF DEATH
DEC. 23, 2010 6: 17 A.M. PRESTON, IDAHO FRANKLIN
CAUSE OF DEATH (underlying cause last) Approximate Interval Between
a. Oneeyand Death
PNEUMONIA DAYS
DUE TO (or as a consequence of):
b.
DUE TO (or as a consequence of):
c.
DUE TO (or as a consequence of):
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH but not resulting In the underlying cause given above WAS AN AUTOPSY
PERFORMED?
NONE STATED J NO
MANNER OF DEATH NAME OF CERTIFIER TITLE
NATURAL DAVID B. BECKSTEAD, M.D. PHYSICIAN
CORONER SUBSEQUENT CERTIFICATION IF NECESSARY
TIME OF INJURY PLACE OF INJURY
This is a true and correct reproduction of the document 'officially registered and placed,
on file with the IDAHO BUREAU OF VITAL RECORDS AND HEALTH STATISTICS.
DECEMBER 27, 2010
DATE ISSUED•
This copy is not valid unless prepared on engraved border
displaying state seal and signature of the Registrar.
State File No 2010
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CERTIFICATI ITAL RECORD
ATTACHED EXHIBIT "A"
LOT NO. 3 OF BLOCK NO.1 TOWNSITE OF GROVER, LINCOLN COUNTY, WYOMING.
Together with all water rights, mineral rights, improvements and appurtenances thereon situate or in
anywise appertaining thereunto.
00669
Subject, however, to all reservations, restrictions, exceptions, easements and rights -of -way of record or
in use.