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jandTtleCo
SINCE 1904
RECEIVED 10/10/2012 at 4:28 PM
RECEIVING 967314
BOOK: 796 PAGE: 35
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT
I, GEORGIA SMITH being first duly sworn on oath, depose and say:
That I am a citizen of the United States of America over the age of 21 years, and a
resident of WYOMING.
That I was well and personally acquainted with FRANCES SMITH in that certain
Warranty Deed dated APRIL 22, 2002 and recorded in Book 488, at Page 202, as Filing No.
880535 in the office of the Recorder of LINCOLN County, WYOMING.
That I know of my own knowledge that FRANCES SMITH in the said deed and
mentioned in the attached Certified Copy of Certificate of Death was one and the same person.
This affidavit is intended to terminate the JOINT TENANTS WITH FULL RIGHTS of
SURVIVORSHIP in the following described property:
Lot 5 Buckskin Crossing Subdivision, Lincoln County, Wyoming, according to that plat filed
August 15, 1996 in the Office of the Lincoln County Clerk as Plat No. 375
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.
LEGAL DESCRIPTION
Tax Roll No. 3619 341 000 -3400
Dated this day of Q i.-- 0122 A.D.
00035
Commission expires:4P -3/ (p
Residing in:SA Wy
INDIVIDUAL ACKNOWLEDGMENT
STATE OF WYOMING
S
County ofn p e i a
On the I day of OcAob.p ;r A.D. 2012 personally appeared before me
be on >or\ C
the signer(s) of the within instrument, who duly acknowledged to me that he /she /they executed
the same.
L dths5 Public
LEA WELLS
COUNTY OF
SHERIDAN
NOTARY PUBLIC
STATE OF
WYOMING
MY COMMISSION EXPIRES AUGUST 23
0003'
CERTIFICATI ON OF VITAL RECORD
Other Significant
Conditions:
Manner of Death:
Certifier:
TyP e:
Name:
Address:
Date Filed:
Decedent: State File Number:
Name: Frances Miles Smith
Gender: Female Social Security Number:
Date of Birth: November 20, 1921 Age at the Time of Death:
Date and Place of Death:
Date of Death: August 11, 2012 County of Death:
City of Death: Sheridan
Location: 2153 Pima Dr.
Additional Decedent Information:
Place of Birth: Little Pine, Minnesota
Residence: Sheridan, Wyoming
Marital Status: Widowed
Armed Forces: No
Name of Father: Ralph Miles
Name of Mother: Pricilla Rautsaw
Informant: Georgia Smith
Disposition:
Method of Disposition:
Place of Disposition:
Funeral Home or Facility:
Facility:
Burial
Family Ranch, 390 Lower Prairie Dog Rd, Sheridan, WY 82801
Kane Funeral Home,' Sheridan, Wyoming
Cause of Death:
The immediate. cause is listed on the first line followed by any underlying causes.
(a) Failure to thrive
(p) ?7
(c) Cardiac. pacemaker
Natural Death
Physician
William Williams, M.D.
1456 W. 5th Street, Sheridan, Wyoming 82801
August 29, 2012
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming.
DATE'ISSUED :Thursday, August 30, 2012
L This copy is not valid unless prepared on paper with an engraved border.
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
Daughter
Interval:
Time of Death: 16:10 (Actual)
amc?•
James McBride
Deputy State Registrar
0003.7
2012- 002554
90 years
Sheridan
v