HomeMy WebLinkAbout967574Affidavit of Survivorship
I, Lillian J. Robertson, being of lawful age and duly sworn according to law, upon
my oath, depose and state:
That under the date of August 18, 196o, for valuable consideration, Kemmerer
Improvement Corporation, a Wyoming corporation, by deed of that date, which deed
was duly filed of record in the Office of the Lincoln County Clerk, on August 22, 196o, in
Book 45PR, Page 361, conveyed to Gayle G. Robertson and Lillian J. Robertson, as
tenants in entireties and not as tenants in common, the following described land, in the
County of Lincoln, State of Wyoming, to -wit:
Lot Numbered 6 in Block Numbered 2 of Sunset Subdivision, Town of Kemmerer, as
surveyed, platted and recorded
That by reason of said conveyance aforesaid, the said Gayle G. Robertson and
Lillian J. Robertson, as tenants in entireties, 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 Gayle G. Robertson, also known as Gayle Gordon Robertson, on the 1st
day of October, 2012. That by reason of and upon the death of Gayle G. Robertson, title
in the above described real property vested in Lillian J. Robertson.
Affiant avers and certifies that Gayle G. Robertson, also known as Gayle Gordon
Robertson, is the identical party named with Lillian J. Robertson 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 14: day of 2012.
State of 11.-11.1. I 1-)62_
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County of U 4 4J
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WITNESS my hand and official seal.
00 6
Lillian J. Robertson
Subscribed and sworn to before me, a notary public in and for said County and
State, by Lillian J. Robertson, this 6 of stc, e 2012.
Notary Public
RECEIVED 10/26/2012 at 4:06 PM
RECEIVING 967574
BOOK: 796 PAGE: 856
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
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CERTIFICATI
D INF MA
October 2012
City of peath:
Age: Place of Birth: 83
ArmedService§ No
Spouse's Name:_ Lillian Jane Kasza
asfr
Irldy/Business Hospital
KeMmerer, Wyoming
Mabel Irene Edwards
TION
Intermountain Medical Cen
A
Date of Death: r
Salt Lake City
Sumner, Nebraska
Residence:
Mother's;
facility or Address:
INFORM NT INFORMATION w
N ame: Lillian' Jane Robaitson
M 1A ailing Addre 418 Beec enue, Kegimerer
DISPOSITION INFORMATION
Method of Disposition: Cre
Place of Disposition:: Uta
Date =of,Disposition: Oats;
MEDICAL CERTIFICAT4
MedicaLPrafessional
CAUSE OF DEATH
\Respiratory Failure
Due:to.(or as a conseg
Due to (or as a consequ
Other significant -condition
Tobacco '/Use Probably;Co
Medical, Examr C
ineontacte
FUNERAL HOME INF Til N
Funeral Hoe: randall F9neral Hot,,
Address: O Box 41;105 East'Center, Str et ama"
•Funeral' Director:
D'on VamBoerum MI
D ri ermountain-.Me�a
84157
CERTIFICATE OF DEATH
State File Number 2012011938
Gayle Robertson
neraLDirectors Cremation enter Soi
r 30 =12
Date Registered:-0ctober 3 2Q12
Date Issued. October 16; 2012_
AMENDMENT_HISTORY
10/08/2012 Birth Cityrom Gering to'Sumner
,t.4 Janice L Houston, StateRegistrar
Time of Death:
County of Deatfi
Date pfBirtV,
=Sex:
MantaT tafus:
Usual Qccupation,
Education:
Father's Name:
Facility Type:
_Re lat ion sh i
0.mir OW 1
of) Glonic Dlst
n ibuted Surgical�Rai�
r of) Colon Obst
D Lund Malignant ,_H eart Failure
A
Autopsy,.Perf
G No of
This is an exact reproduction of the: document registered in the State Office of1[itaY -Statistics
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docuent displays the date, seal and signature of the State Registrar and the County /District' Health Officer.
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