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Home My WebLink About967680When recorded mail to: I. Glenn Perkins 111 Maplewood Avenue Pocatello, ID 83204 Comes now the undersigned I. Glenn Perkins and being on oath first duly deposes and says: 1. That I am a citizen of the United States of legal age and capacity, and competent to make this affidavit. 2. That I was personally acquainted with the deceased, Mary D. Perkins 3. That said deceased is one in the same person as Mary D. Perkins listed in that certain document as recorded on December 7, 2006 at Entry No. 925133 in Book 642 at Page 473 in the office of the Lincoln County recorder, State of WY. 4. That the purpose of this affidavit is for I. Glenn Perkins to accept the Trusteeship of the Glenn Perkins Family Living Trust, dated November 11, 1985 and hereby agree to act as Trustee of said Trust on all the terms, provisions and conditions specified in said Trust. 5. That a certified death certificate of the deceased is hereby attached. Beckwith Parcel Lots Six (6), Seven (7), Fourteen (14), and Fifteen (15) of Section Seven (7) in Township Twenty -Two (22) North Range one hundred Nineteen (119) West of the Sixth Principal Meridian, Wyoming Together with all water rights thereunto belonging or in any -wise appertaining. State of Idaho County of g V111 ss: AFFIDAVIT AND ACCEPTANCE OF TRUSTEESHIP On October 2012 personally appeared before me I. Glenn Perkins, Trustee, of the Glenn Perkins Family Living Trust, Created by instrument dated November 11, 1985, and the signer(s) of the within instrument, who duly acknowledged to me that They executed the same. t1 G eq► RECEIVED 10/31/2012 at 9:33 AM RECEIVING 967680 BOOK: 797 PAGE: 217 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY I. Glenn Perkins, Trustee 6e,elAsr» Notary Public" Commission Expires 0 l I 1 "Z-0)% 0021? r- 4/5 'fe e__.. VITAL RECORD TYPE OR PRINT IN PERMANENT BLACK INK 00 NOT USE FELT TIP PEN. FOR INSTRUCTIONS SEE HANDBOOKS IF DEATH WAS DUE TO GTHER THAN NATURAL CAUSES. THE CORONER COMPLLETE AND SIGN THE CERTIFICATE PENCO (Rev) 07/10 STATE OF IDAHO IDAHO DEPARTMENT OF HEALTH AND WELFARE BUREAU OF VITAL RECORDS AND HEALTH STATISTICS State of Idaho CERTIFICATE OF DEATH u,se rl.a tx, 0oK ioi° iru isuwwi: r ,Z,37,:yyuiois+ny=cooeaae Local Reg. No. DISPOSITION PLACE OF DEATH DATE OF DEATH CAUSE OF DEATH ITEMS 32 -30 TO BE USED OR EXTERNAL CAUSES ONLY (CORONER) 1.DECEDENT'S LEGAL NAME (Include AKA's it any) (First; Middle. Last Suffix) c MARY D. PERKINS N r 40. AGE-Last Birthday ;4b.UNDEk 1 YEAR AC. c. UNDER 1 DAY 5. DATE OF BIRTH (MO /DayM) Months Days Hours Minutes o 87 (veers) 08/20/1924 rV 7a: RESIDENCE STATE OR FOREIGN COUNTRY '71). COUNTY N IDAHO BANNOCK 7d. STREET AND NUMBER 111 MAPLEWOOD AVE L. B. MARITAL STATUS AT TIMEOF DEATH c 0 Married Q Married. but separated 0 Widowed DNOrce0 0 Never married Q Unknown 4, 10. EVER W U.S. 11a. FATHER'S NAME (1irsl, Middle. Last, Suffix) 'c ARMED FORCES? THURLOW W. O'NEILL y 0 Yes 12a. MOTHER'S MAIDEN NAME E No FRANCIS M. JULIAN O C. 13a. INFORMAANT'S S NAME (Type or print) Z I. GLENN PERKINS Q 14. METHOD OF DISPOSITION 0 Burial )Cremation 0 Donation 0 Entombment O 0 Removal from Idaho Other(Specify) 2. SEX 3. SOCIAL SECURITY NUMBER FEMALE S. BIRTHPLACE (City and 51 1 Territory, or Foreign Country) SAGE, WYOMING 7c. CITY OR TOWN POCATELLO '7e. APT. NO. '7f. ZIP CODE 79. INSIDE CITY' 83204 LIMITS? Yes D No 9. SURVIVING SPOUSE'S NAME (11 wile, give maiden name) I. GLENN PERKINS 116. BIRTHPLACE (State, Territory, or Foreign Country) WYOMING 12n. BIRTHPLACE (SI e le, Terri) ry, or.FOieign Country)" WYOMING 13b. RELATIONSHIP TO DECEDENT :13c. MAILING ADDRESS )Street and Number, City, Slate. Zip Code). HUSBAND P.O. BOX 683 POCATELLO, ID 83204 '15. PLACE OF DISPOSITION (Name and address of cemetery. 16. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY crematory. other place) PORTNEUF VALLEY CREMATORY DOWNARD FUNERAL HOME 241 NORTH GARFIELD AVENUE 241 NORTH GARFIELD AVENUE POCATELLO, IDAHO 83204 POCATELLO, IDAHO 83204 'tTa. SIGNATURE OF FUNERAL SERVICE LICENSEE OR PERSON ACTING ASSUCH '17b LICENSE NUh1BER (OI bcensee) 18. WAS COCAUSR CONTACTED DUE TO CAUSE OF DEATH? ELECTRONICALLY FILED: LANCE R. PECK M0821 D Yes No PLACE OF DEATH (19 -22) 190. IF DEATH OCCURRED IN A HOSPITAL: 191). DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL: 10 Inpatient 2 DER /Oulpallenl 3 000A 4 DHOSpioe facility 5 I] Nursing home /Long lean, care Monty 6100ecedenfs home 70 Other (Specify) 20.FACILITY NAME (ITEM lacilily,.give street and number). •21. CITY; TOWN, OR LOCATION OF DEATH, AND ZIP CODE COUNTY OF DEATH 111 MAPLEWOOD AVE POCATELLO, ID 83204 BANNOCK '21 24. TIME OF DEATH 25. DATE'PRONOUNCEO OEAD(MolDay/Yr) (Spell morally 26 TIME PRONOUNCED DEA (24116 124h0 20:40 May 17, 2012 20 :40 27. CAUSE OF DEATH PART,(. Enter the chain of events -diseases. injuries, or complications -Thal directly caused the death. DONOT enter terminal events such as cardiac Approximate Interval: *nest respiratory arrest, or venlncular fibrillation without showing the etiology. DONOT ABBREVIATE. Enle1 only one cause on a line' Onset to Death IMMEbIATE CAUSE (Final PNEUMONIA DAYS. disease or condition -4, DUE TO r as a copse f resulting in death) (o consequence o Sequentially list conditions, b DEMENTIA YEARS: ai it any, leading 10 the caus e p listed on line a. Enter the UNDERLYING CAUSE m LAST (disease or )0)ury j final Initiated the events O resulting in death) r PART 6. •Enter ether sianifcanl conditions conlribu)no to death but not resulting n 'be under) m E g' y g cause given in Part I .2Be. WAS AN AUTOPSY AVAILABLE TO COMP 2Bb. WERE AUTOPSY OIMIN P LETE c PERFORMED? COMPLETE THE CAUSE OF DEATH? 29. 0)0 TOB 0 0 Yes No 0 Yes 0 N0 CONTRIBUTE ACCO T O DEATH? 31. MANNER OF DEATH 23. DATE OF DEATH (Mo/DaytYr) (Spell month) May 17, 2012 DUE 70 (or as a consequence of): DUE TO (or as a consequence of), 30.1F FEMALE (Aged 10.94): 0 Not pregnant within past year U Yes 0 Probably D Pregnant Wane ol death Nol pregnant but pregnant within 42 days of death D Not pregnant. but pregnant 43 days to I year before death 0 000000,0 if pregnant within the past year Natural 0 Accident Sutcide 0 Homicide D Pending Invealigotion 0 Could not be determined 33. TIME OF INJURY 34. PLACE OF INJURY (Decedent's home. farm. street, conslrucllon site, (24hr): nursing home. restaurant, lorest, etc.) 32. DATE OF INJURY (MO /Day/Yr) (Spell month) LL 1-' 36. LOCATION OF INJURY: State Cily /Tovin or County Zip Code V Street and Number or Locauon Apartment Number 37. DESCRIBE HOW INJURY OCCURRED. IF TRANSPORTATION INJURY, STATE THE TYPES(S) OF VEHICLE(5) INVOLVED (Aulomob,l pickup motor ycle ANbicycle, etc.) SPECIFY WHICH VEHICLE DECEDENT OCCUPIED. if applicable enger '36b. WHAT SAFETY OEVICES(5) DID DECEDENT USEA:MPL OY7 35. INJURY AT WORK? Q Yes 0 No TRANSPORTATION 3Ba. WAS DECEDENT: 0 Driver /Operator 0 Pa INJURY ONLY 0 Pedestrian 0 Other Speciy) 0 Seal bell ❑Child Safely seat 0 Helmet DAiy bag ❑None 0 Unknaw0 39a. CERTIFIER (Check only one. based on official capacity for this certificate) PHYSICIAN 0 PHYSICIAN ASSISTANT 0 ADVANCED PRACTICE PROFESSIONAL NURSE -To the best of my knowledge, death occurred at the time, dale. and place, and due to the nafuca/ cause(s)/manner slated. 0 CORONER On the basis of examination and/or investigation, in my opinion, death occurred at the lime, dale, and place, and due to the cause(s) and manner staled. Signature and Title of JAY W. WILLEY 39d. NAME, ADDRESS, AND ZIP CODE OF CERTIFIER (Type or p00)) JAY W. WILLEY II, 495 YELLOWSTONE POCATELLO, ID 83201 39b. LICENSE NUMBER 0.00314 39c. DATE SIGNED 5 19 /2012 MM DO YYYY 40a. REGISTRAR'S SIGNATURE 40b. DATE SIGNED 5 71 /2017 MM DO YYYY lll 1 t1,, AT s Y 'NP A \\s y i 4`'� BA illi l y /y i !>!f a yH Ifi 1iI y i1 o Z DATE ISSUED: ,II d f 4 T' 1 M l i r K Lrp% i This copy not valid unless pr pared on engraved border t /p, 5��[�x IV state seal and signature of the Registrar. STATE REGISTRAR 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. IDVAL VALI LID IDV