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Home My WebLink About966385STATE OF WYOMING ss: COUNTY OF LINCOLN say: 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, 20,000 sq. ft. and 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 R119W LINCOLN COUNTY WYOMING," dated 13 May 2002, as revised, Affidavit of Survivorship 1 of 3 00281 7J m C) m m v 03 w CD 01 N W rt 00 N 1, 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 Book 342PR Page 236, Robert C. Humphreys is the record owner of the following described property: NW1 /4SW1 /4, Section 23, T35N, R1 19W, 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. Affidavit of Survivorship 2 of 3 00282 FURTHER AFFIANT SAYETH NOT. DATED this cA day of August, 2012. 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: r 263 SUBSCRII ED AND SWORN to and acknowledged before me, a Notarial Officer, this day of August, 2012, by MARISELA HUMPHREYS. Notarial officer Affidavit of Survivorship 3 of 3 CERTIFICATION OF VITAL RECORD ■tP This copy not v: d unless prepared on engraved border displaying state seal and signature of the Registrar. NINCO(Ro.)Wn0 DISPOSITION PLACE OF DEATH DATE OF DEATH CAUSE OF DEATH ITEMS 32 -38 TO BE USED FOR EXTERNA CAUSES ONLY (CORONER) lbetei,Yl1l.11 1.DECEDENT'S LEGAL NAME (Include AKA's If any) (Firsr,.Middle, Last, Suffix) B ROBERT CLARK HUMPHREYS •11 AGE -Last Birthday 4a: ,d b.UryDER 1 YEAR 14C. UNDER 1DAY 5. DATE OF BIRTH (MolOay/Yr) 0 Months Days Hours _Minutes 62 (veers)' 05/01/1950 m 7a RESIDE NCE -STATE OR FOREIGN COUNTRY Tits. COUNTY in WYOMING LINCOLN 7d STREET AND NUMBER g 105762 HIGHWAY 89 N: T TIME B. MARITAL STATUS AT TIME OF DEATH tL El Married Married. but separated Widowed ()Nomad Never married Unknown TUTS. 00 L t, uf 10 EVER 14a: FATHER'S NAME (First, Middle, Last, Suffix) •C ARMED' j FORCES? 1 DEAN G HUMPHERYS m Yes !:12a. MOTHER'S MAIDEN NAME (First, Middle, Last, Suffix) E El No NEVA CLARK o O 13a, INFORMANT'S NAME (Type or print) 1136. RELATIONSHIP TO DECEDENT 2. SEX 3. SOCIAL SECURITY NUMBER MALE 8. BIRTXPLACE;(Cily and Slal Ternlory, or Foreign CDUnlry) AFTON, WYOMING 7c. CITY OR TOWN ETNA 17e APT. NO. 7t LIPICOOE 179 INSIDE CITY LIMITS? 87118 ❑yes 1E1 No 1 i 9.SURVIVINO. SPOUSE'S NAME'(Ilw le give'maiden name) MARISELA ISABEL MARTINEZ its BIRTHPLACE (State. 7emlory, or Foreign Country) WYOMING 1 126. BIRTHPLACE (Stale. Ternlory o FOteign CoUnlry) WYOMING 1 130. MAILING AOORESS (Street and Number, City, Stale. Zip Code) P.O. BOX 5176 ETNA, WY 83118 Z;,. MARISELA HUMPHREYS SPOUSE Q 14. METHOD OF DISPOSITION 115. PLACE OF DISPOSITION (Name and address of cemetery. '18. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY crematory. other place) Ii Buft i ❑Cremal'on IF, ❑:oonalion Entombment ETNA CEMETERY HAWKER`FUNE LL R e moval from Idaho SOUTH' SHILLING` AVENUE 2 Other (Specify) ETNA, WYOMING 83118 BLACKFOOT, IDAHO 83221 17a, SIGNATURE OF FUNERAL SERVICE LICENSEE OR PERSON ACTING AS SUCH 717h. LICENSE NUMBER (Of licensee) ;S..i1e. WAS- COCTED 1 OUETO CORONER CAUSE OFDEA I' ELECTRONICALLY FILED: KEVIN T. DIETRICH I M0748 Yes la No PLACE OF DEATH (19 -22) 19a. IF DEATH OCCURRED IN A HOSPITAL: 19b, IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL: 1123 Inpatient 2. 0ER /Outpatient 3 0130A 4 ❑Hospice facility: 5 Nursing home/Long term care facility a ['Decedent's home 7❑, Other (Specify) •20 :FACILITY NAME (II Dal facility; Siva street and number) 21: CITY, TOWN, OR LOCATION OF DEATH, AND ZIP CODE i' 22. COUNTY :OF:DEATH PORTNEUF MEDICAL CENTER POCATELLO, ID 83201 BANNOCK 24. TIME OF DEATH 1 25. DATE PRONOUNCED DEAD(MG/ Day /Yr) (Spell month) 128. TIMEpRONOUNCE0:0EAD (24M). (24h0 17:15 June 16, 2012 1.7:15 CAUSE 27. US OF DEATH PART I. Enter the chain of events.- diseases, injuries, or complications -that directly caused the dean. 00 NOT enter terminal events such as cardiac Approximate Interval: 'arrest; respiratory arrest or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter: only one cause on a line:;: Onset to Death IMMEDIATE CAUSE (Float CARDIAC DEATH SUDDEN CA AC_U_TE_ disease or condition a resulting In death) DUE TO (Or a consequeneeo0: 23. DATE OF DEATH (Mo/Day/Yr) (Spell month) June 16, 2012 'Sequentially 1151 conditions. O Iisted»n)nle leading ter Me O UNDERLYING 'CAUSE LAST.(disease 0, inldry Ihal inffatad ne'evenls p resulting In death) 2 r PART ILEnler 0 29. DID TOBACCO USE CONTRIBUTE TO DEATH? Yes Probably. 010 Unknown b UNKNOWN DUE TO (or as a consequence of): DUE TO (bras 3 consequence:oI: WAS AN AUTOPSY 271b. WERE AUTOPSY FINDINGS: PERFORMED `'T AVAILABLE TO COMPLETE THE CAUSE OF DEATH?. Yes No CI Yes Na 3.t- ..MANNER OF DEATH 130.1F FEMALE (Aged 1054): Not pregnant within past year Not pregnant, but pregnant 43 days Pregnant al lino of death to 1. year before death 1 Natural Homicide Not pregnant, but pregnant' Unknown 4 pregnant within the past Accident ❑Pending In005tigelion within 42 days of dean year ❑Suicide Could not be determined -32. DATE OF INJURY(Mo/OayfYr) 133.TIME OF INJURY 34 PLACE OF INJURY (Decedent's home. farm; street, construction site, I.: 35. INJURY AT WORK? W (Spell month) 124hr)1 nursing home, restaurant. forest, etc.) .YO x.38. LOCy cc Street and Number or Location Apartment Number:. 37. DESCRIBE NOW INJURY OCCURRED. IF TRANSPORTATION INJURY. STATE THE TYPES(S) OF VEHICLES) INVOLVED (Automobile. pickup. motorcycle, ATV. bicycle. etc.) SPECIFY WHICH VEHICLE DECEDENT OCCUPIED, If applicable State City/ Town or County Zip code. TRANSPORTATION 38a. WAS DECEDENT: Driver/Operator Passenger .356. WHAT' SAFETY DEVICES(S) 0ID DECEDENT USE)EMPLOY? I INJURY ONLY Pedestrian Other (Specify) Seat belt' i ❑�ChiM safely seal (];Helmet ❑A ir bag'. 0 None 0 Unknown 39a. CERTIFIER (Check only one, based on official capacity tot this certificate) ":396. LICENSE NUMBER 1$1 PHYSICIAN PHYSICIAN ASSISTANT ADVANCED PRACTICE PROFESSIONAL NURSE To the best of my knowledge, death occurred at the lime, date, and place, and due to the ag 2502) cause(s7manner Mated. CORONER -0n the basis of examination and /or investigation, In my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner slated. Stgnatureand TllleofCertigar/ DAVID M 90NZAIEZ_((A,D.._ 39d. NAME, ADDRESS, ANO ZIP CODE OF CERTIFIER (Type or print) DAVID M. GONZALEZ, 777 HOSPITAL WAY POCATELLO, ID 83201 M -09795 390. DATE SIGNED 6 25 2012 MM 00 YYYY 40a: REGISTRAR'S SIGNATURE 40b.OATE SIGNED 1017 TYPE OR PRINT IN' PERMANENT BLACK 480 Do NOT USE FELTTP PEN FOR INSTRUCTIONS SEE HANDBOOKS IF DEATH WAS DUE TO OTHER TNAN,NATURAI. CAUSES, THE CORONER COMPLETE AND SIGN THE CERTIFICATE 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, IDAHO DEPARTMENT OF HEALTH AND WELFARE BUREAU OF VITAL RECORDS AND HEALTH STATISTICS State of Idaho CERTIFICATE OF DEATH ri. coxov. les oocwEcTrrnRS25vnesr.TeRewsrRw e vnrN Txeoee.wwrosHwsrNSeowsvAee ow Re.NU. °iuiseosuL:auis esusaS sADESMOwce arrwsoeAnr usow F ts.lmum l X:>A,2ele c ooE 9: JAMES B. AYDELOTTE STATE REGISTRAR 0 ':111 VOA 0 JSJJ 1I71inap