HomeMy WebLinkAbout967078STATE OF WYOMING
SS.
COUNTY OF LINCOLN
I, Donald H. Larsen being of lawful age and duly sworn according to law upon my oath
and depose and state:
1. That I am of adult age, a resident of Kemmerer, Wyoming, and the Affiant herein.
2. That by virtue of the conveyance which is recorded in the Office of the Clerk for Lincoln
County, Wyoming, located at Kemmerer, Wyoming in Book 384PR on page 432 is
recorded a Warranty Deed dated June 13, 1996, which conveys unto Rose M. Lebolo,
Pauline S. Bernatis and Donald H. Larsen as joint tenants, the following property more
particularly described, to -wit:
Commission Expires:
Lots 15 and 16 of Block 4 of the Fairview Addition to the Town of
Kemmerer, Lincoln County, Wyoming as described on the official plat filed
as Plat No. 188 of the records of the Lincoln County Clerk.
3. That said Rose M. Lebolo, aka Rose Mary Lebolo died on the 12th day of August, 2012,
and a copy of the original certificate of death, certified to an a 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 Rose M. Lebolo, aka Rose Mary Lebolo and by reason of
state statutes, the decedents interest and title in said property has terminated and title to
the real property conveyed thereby has vested absolutely in Pauline Bernatis and Donald
H. Larsen continuously since the death of the said decedent.
FURTHER AFFIANT SAYETH NOT.
hg, foregoing instrument was subscribed and sworn to before me by Donald H. Larsen
this 1(&L day of September, 2012.
Witnessed my hand and official seal.
RECEIVED 9/27/2012 at 2:04 PM
RECEIVING 967078
BOOK: 794 PAGE: 826
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT
/OW
Donald H. Larsen
00820
Notary Public
SHELLEY SANOALL NOTARY Pu ljc
State of
Vhortung
Decedent: State File Number: 2012 002504
Name: Rose Mary Lebolo
Gender: Female Social Security Number:
Date of Birth: November 12, 1921 Age at the Time of Death: 90 years
Date and. Place of Death:
Date of Death: August 12, 2012 County of Deaths Lincoln
City of Death: Kemmerer ll
Location: South, Lincoln Medical Center PO Box 390
\I
Additional Decedent Information:
Place of Birth: Sublet, Wyoming
Residence: Kemmerer, Wyoming
Marital Status: Widowed
Armed Forces: No
Narile. of Father: ".Louis Marchek
Name of Mother Mary Maklancic
Informant: Pauline Bernatis Relationship: Daughter
Disposition:
Method of Disposition: Cremation
Place of Disposition: UFD Cremation Center, South Jordan, Utah
Other Significant
Conditions:
Manner of Death: Natural Death Time of Death: 05:25 (Actual)
Certifier:
Type: Physician
Name: Chad Seiler, M.D.
.Address: PO Box 390, Kemmerer, Wyoming, 83101
Date Filed: August 24, 2012
(a) Congestive Heart Failure
(b) Acute Myocardial Infarction
Funeral Home or Facility:
Facility: Ball Family Chapel, Evanston, Wyoming
Cause of Death:
The immediate, cause is listed on the first line followed by any underlying causes.
444 44446 444 64 14 46 66666 40616666 6 6.6 66,616.0.14616
This is a• true certification of the document on file in the office of Vital
Statistics. Services;; Cheyenne, Wyoming.
DATE ISSUE[onday, August! 27, 2012
This copy is not valid finless prepared on paper with an engraved border.
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH 0 0 8 2
James McBride
Deputy State Registrar
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CERTIFICATI VITAL RECORD
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