HomeMy WebLinkAbout967042Affidavit of Survivorship
I, Patricia R. Collier, being of lawful age and duly sworn according to law, upon
my oath, depose and state:
That under the date of May 22, 2007, for valuable consideration, Robert E.
Gordon and Isobel M. Gordon, by deed of that date, which deed was duly filed of record
in the Office of the Lincoln County Clerk, on May 25, 2007, in Book 659, Page 402,
conveyed to Frederick J. Collier and Patricia R. Collier as joint tenants, the following
described land, in the County of Lincoln, State of Wyoming, to -wit:
Lot 611 of Star Valley Ranch RV Park Plat Two as platted and recorded in the Official
Records of Lincoln County, Wyoming
That by reason of said conveyance aforesaid, the said Frederick J. Collier and
Patricia R. Collier 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 Frederick J. Collier, also known as Frederick James Collier, on the 1st day of
November, 2010. That by reason of and upon the death of Frederick J. Collier, title in
the above described real property vested in Patricia R. Collier.
Affiant avers and certifies that Frederick J. Collier, also known as Frederick
James Collier, is the identical party named with Patricia R. Collier in the aforementioned
deed, whose death terminated his 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 y
da of 12.
State of GU tit i.
c
S ss.
County of
Subscribed and sworn to off9 me, a wary publi in and for said County and
State, by Patricia R. Collier, this "'day of ,v_ febi1, 2012.
WITNESS my hand and official seal.
My Commission Expires:
This Document is being recorded by
Aocky Mountain Title Insui'irtc! Aging
Of Llncoin County as-e COURTESY 0*
i
NANCY J BROWN NOTARY PUBLIC
County of r Stole of
Lincoln Wyoming
My Commission Expires June 25, 2074
-P1 5i17 L
Patricia R. Collier
RECEIVED 9/25/2012 at 2:32 PM
RECEIVING 967042
BOOK: 794 PAGE: 678
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
00678
Notary Public
1
EVX
w' IJTINh IP►%IP I w
CERTIFICATION OF VITAL RECORD N
qe
TYPE OR
PRINT IN
PERMANENT
BLACK INK
DECEDENT
5.:RACE White.
(Specify)
IF DEATH
OCCURRED IN
INSTITUTION
SEE HANDBOOK
REGARDING.:'
i COMP.I•ETICN: OF
`RESIDENCE'
'ITEMS
PARENTS
DISPOSITION
CAUSE OF
DEATH:
CONDITIONS IF
ANY WHICH
GAVE RISE TO
IMMEDIATE::"
CAUSE •�7
STATING THE
UNDERLYING
CAUSE LAST'
0 "JP
r.,
la. DECEASED -NAME (FIRST;MIDDLE,LAST,SUFFIX)
Frederick James COLLIER
3b. CITY, TOWN, .OR LOCATION OF DEATH
Pahrump
9a. STATE OF BIRTH (If not U:S:A,
name count rybistrict Of Columbia
1:3. SOCIAL:SECURITY NUMBER
5a. RESIDENCE, 'STATE
Nevada
16. FATHER NAME
8a. INFORMANT- NAME (Type or Print):_
Patricia COLLIER
20a. FUNERAL DIRECTOR SIGNATURE (Or Person Acting as Such)
JAMES LEE
SIGNATURE AUTHENTIC/ TED
TRADE CALL WADE CALL NAM AND A0DES
PART II
a
(b)
28e. INJURY AT WORK(Specify
Yes or No)
25a. ACC., SUICIDE, UNDET.:
.OR PENDING INVEST. (Specify)
(d)
(First Middle Last Suffix)
James Emery Meade COLLIER
DUE TO, OF;:
DUE TO, OR AS A CONSEQUENCE OF:
(C)
t:' DUETO, OR AS A CONSEaUENC :OF:
DATE ISSUED:
DEPARTMENT OF HEALTH AND HUMAN` SERVICES
DIVISION OF HEALTH 0067
VITAL STATISTICS
CERTIFICATE OF DEATH 201'0016951
STATE FILE NUMBER
15b. COUNTY
Nye`
3c. HOSPITAL OR OTHER INSTITUTION -Name(If not either, give street
and number)
28b. DATE OF INJURY (Mo/Day/Yr)
11115/2010
5150 Oak Ridge #42 A
6. Hispanic Origin? Specify 7a. AGE -Last
No Non Hispanic birthday (Years)
9b. CITIZEN OF WHAT COUNTRY 10.EDUCATION
United States 13
14a. USUAL OCCUPATION (Give Kind of Work Done During MoSt of
Working Life, Even If Retired) Accountant
15c. CITY, TOWN OR LOCATION)
Pahrump
20b. FUNERAL
DIRECTORODENSE'
69
a To the best of lny;knoYaladge death o'cqufted at the time; date :Ohd place and:
u due to the causes) s tated; !(Signature T)tle) SIGIVATUREAU7 IENTICII
MICHELLE LEIGH STACEY MA.`
CERTIFIER :7a- 21b. DATE SIGNED (Mo /DayTYr) 21c. HOUR OF DEATH
z November 02, 2010 06:42
N
m 21d NAME:OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER
w (Type or Print)
25. CAUSE "(ENTER ONLY :ONE CAUSE :PER LINE,FOR (a), (b), AND (c).).
PART'.) Pancreatic' Cancer
28c. HOUR OF INJURY
28f, PLACE :OF INJURY -At home, farm, street, factory office
building,. etc. (Specify)
'STATE" REGISTRAR
L oF' 360666' CERTIFIED COPY :OF VITAL RECORDS
This is a true and exact reproduction of the document officially registered and
y t, placed on file in the office of the State Registrar and Vital Records.
1 %sue
2. DATE OF DEATH (Mo /Day/Year) c 3e. COUNTY OF DEATH
November 01 2010'
3e.lf Hosp.•cr Instaindicate D:OA;OP /Emer. Rm
Inpatient(Specify)
Home
7b. UNDER 1 YEAR17c. UNDER 1 DAY
MOSI DAYS HOURS MINS
t4b: KIND OF BUSINESS OR INDUSTRY
FederaFGovernment
15d. STREET AND NUMBER
5150 Oak Ridge #42 A #42 A
17. MOTHER NAME (First Middle i.asl Suffix)
Gladys I AYt�]ES;
18b. MAILING ADDRESS (Street or R.F:D. No, City or Town; State(iZip)
5150 Oak Ridge #42 A Pahrump, Nevada 89048
9a. BURIAL.CREMATION, REMOVAL; 'OTHER (Specify) 19b. CEMETERY OR CREMATORY NAME.'
Cremation i Pahrump Crerliatory
E 22b. DATE SIGNED (MD /Day/(r)
O
G
0 0 22d. PRONOUNCED DEAD,(M'b /Day/Yr)
23a. NAME AND ADDRESS 'OF CERTIFIER (PHYSICIAN; ATTENDING PH NIEDICAL:EXAMINER OR CORONER) (Type orPrill)
MlEhelle Lath Stacey M.D. 1401 S Hwy 160 Ste B' Pahrump NV 89048
24a. T U
REGISTRAR (Signature) 240 DATE R BY REC'1STRAR 24
SIG
REGISTRAR JEWELL
l REAUTHEN T TICATE
(Nto /Day/Yr)
p NoVember:l3 2010'?,
28d, DESCRIBE HOW INJURY OCCURRED
:28g;ZOCATION
This copy is not valid unless prepared an engraved border displaying date seal and'signature of Registrar.
STREET OR R.F.D. No.
S/GNATUA i9
26: AU.T0P..SY''::
(Specify Yes::iiNNNo)
CITY OR TOWN
Nye'
4. SEX
8 DATE OF BIRTH (Mo /Day/Yr)
..May 23, 1944
11. MARRIED,:NEVER MARRIED, WIDOWED 12 SURVIVING SPOUSE (Ifwife, give
DIVORCED (Specify) M aYtied maiden name) l5 tnoia ROHLING,'
;Ever In, US.Armed;:.:
_Forces?
15e' INSIDE CITY
LIMITS (Specify Yes
or.No) No
19c. LOCATION City or Town State
Pahrump Nevada :89048
120o.`NAME ANI):ADORESS OF FACILITY
Pahrump Family Mortuar
`5441 S. Vicki Apn Pahtump NV.:•d904g
a 22a. On the basis'ofexamination and /ors investigation, in my opinion death occurred at
0 the pme date and place and due to thecause(s) stated. (Signature'.& Title)
22eP.RONOUNCED:DEAD:AT (Hour
220' HOUR OF:DEATH;
23b.. LICENSE NUMBER'
11436.
bEATH DUE >TO COMMUNICA9LEDISEASE
YES:iQ NO E3
-.interval between Onset and death;
p:: Interval between onset.and death,..
:Interval: between onset'and death
Interval between onset and death
21. WAS'CAS8. REFERRED:;;
TO CORONER (Specify 1'es:
Or NC) No
STATE
VRS- Rev 20:100218
OF, FvgO "'If4