HomeMy WebLinkAbout967749Affidavit of Survivorship
I, Thomas Vincent Pierce, being of lawful age and duly sworn according to law,
upon my oath, depose and state:
That under the date of August 4, 2004, for valuable consideration, Michael A.
Decker and Debbie M. Decker, husband and wife, by deed of that date, which deed was
duly filed of record in the Office of the Lincoln County Clerk, on August 6, 2004, in Book
564PR, Page 256, conveyed to Thomas Vincent Pierce, Robert M. Smith and Marion A.
Smith, joint tenants with rights of survivorship, the following described land, in the
County of Lincoln, State of Wyoming, to -wit:
Lots 2 and 3 of Block 1 of Amended Plat of Red Bluff Addition, Phase 1 to the
Town of LaBarge, Lincoln County, Wyoming as described on the official plat
thereof
That by reason of said conveyance aforesaid, the said Thomas Vincent Pierce,
Robert M. Smith and Marion A. Smith 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 Robert M. Smith, also known as Robert Mack Smith, on the loth day of
December, 2004. That by reason of and upon the death of Robert M. Smith, title in the
above described real property vested in Thomas Vincent Pierce and Marion A. Smith, as
the surviving joint tenants.
Affiant avers and certifies that Robert M. Smith, also known as Robert Mack
Smith, is the identical party named with Thomas Vincent Pierce and Marion A. Smith 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 day of 2012.
State of
ss.
County of 01 ilti
Subscribed and sworn to before me a notary! c in and for said County and
State, by Thomas Vincent Pierce, this day of G'�" 2012.
WITNESS my hand and official seal.
RECEIVED 11/2/2012 at 3:08 PM
RECEIVING 967749
BOOK: 797 PAGE: 471
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
My Commission Expires: Fe i 201 -C'
Thomas Vincent Pierce
0047
CHRISTINE LONG
Notary Public
State of Utah
Comm. No. 65182T
My Comm. Expires Feb 3.2016
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CERTIFICATION OF VITAL RECORD s
ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE
LOCAL FILE NUMBER 049 -2004
1. DECEDENTS LEGAL NAME f nclude AKAS, l`any) (First, Middle Lest)
Robert: Mack Smith:
I Male
4. SOCIAL SECURITY NUMBER
7a. PLACE OF DEATH (CNeckYmly ono)
IF DEATH OCCURRED IN A HOSPITAL l IF DEATH OCCURRED SOMEWHERE OTHER THAN A N0$PITAL
75 FACILITY NAME (If not nsl10600. give sheet end number( 7c. CITY' TOWN, OR LOCATION OF DEATH 7d. COUNTY OF DEATH
Marbleton -Big Piney Medical Clin Marbleton Sublette
8 BIRTHPLACE (609 and slate or foreign 00400) 9 MARITAL STATUS 90 TIME OF DEATH 1 0. SURVIVING SPOUSE 10 g e no o P 00,10 loss 010800ge)
�3lgdamed M d but eepe 'bd CXa :w yea Marion Alene Isaacs
Big Piney, Wyoming ❑ANdrgad ONeYerreerded Dud
Ii EVER IN U S 12a RESIDENCE
STA T E 1 2b COUNTY 120 CITY TOWN OR LOCATION
ARMED FORCES, OYES LINO Wyoming Sublette Big Piney
120 STREET AND NUMBER 120 ZIP CODE '121 INSIDE CITY LIMITS
248 North Big Piney Road 83113
DYES ONO
13. FATHER'S NAME (First. Middle, Last)
Mark Venice Smith
160 INFORMANTS NAME
Marion A. Smith
18e SIGNATURE (or Perso OF n 4611n s such) L'SEfj LIiENSEF
g as SUCK) E� 4 81
20. ACTUAL OR PRESUMED TIME OFD D
il.necessary..
IMMEDIATE CAUSE (Final d,s0esa or
cond,hon resulting in death)
Sequentially 1Lt conditions, Ifey,
leadtng to the cause listed on line
Enter the UNDERLYING CAUSE
(disease 00
injury that irati8ted
Vents resulting in dealh)LAST
30. DATE OF INJURY (Mb/Day/Yr)
37b. DATE CERTIFIED (MO/Day/Yr)
I a- /JY is /o
t.
384 RESIST R'S SIGNATUR
5a. AGE Lash. Birthday
(Years) 64
150. RELATIONSHIP TODECE0E
Wife
16. METHOD OF DISPOSITION,":
0 rlal 090061,0
�Gremalion O Ergbmbman
0 Remoyal from Wyoming
0 Odle
17. PLACE OF DISPOSITION (NamO M, r'
k cenamry 6,ematoly)I
Pox Crematory
17b LOCATION CITY OR TOWN AND STATE
Rock Springs, Wyoming,
185. LICENSFNO:
None
5b. UNDER 1 YEAR
Months
2T, DATE PRONOUNCED DEAD (MO /Day /r)
a- o a
Minutes
i'I.r0ec genre Hon
Hazel Adela Beesley
19A.. NAME OF FACILITY T9upso,A t
Chapel of the Pines
CAUSE OF DEA
24. PART L Enter the chain of Wants diseases, tniunes or rSmplroatlsos that directly caused the death DO NOT enter terminal evenls8b6h as cardiac
arrest respiratory arrest, or nlicula J,bnllatol w,NOU(abowmg ltleali0(099 DO NQT ABBREVIATE. Enter only one cable on a l0e Add adddronalines
l l .'fi dn. wit ra
PUETf (04 a o r e 06009180 00 8.,0
b I CC Ir o Se g e roSz5
r. Dugmt., a; A consaml?nc§'otq tf,
c
DUE T O Ior e5 a 0onaeypaeceol)r
15c MAILING ADDRESS (Sl1del a0d Number,Ciry: Slate Zp Code).
248 Ni.„ Piney Rd. Big Piney, WY 83113
PART IL Enter' other s gnilicani condila s contributing t0 death but not resulting in INM,uN
26. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH?
0 YES MI ND
28 IF. FEMALE AGED 1054 i
0 Not pregnant wchin pest year 0 Not pregnant but pregnant 43 days to 1 year before death
0 Pregnant at lime of death 0 Unknown 8 pregnant within the past year
0 Not pregnant bvl pregnant' within 42 days of death
34. LOCATION OF INJURY (Street and number, City or Town, Slate)
32. PLACE OF INJURY'1,9eCede 1 ()pine, cbostruc stte. forest, etc:)
35, IF TRANSPORTATION ACCIDENT SPECIFY',
O Driver /Operator 0Pedeslrian
Passenoa O Othe (Sp tl(
TYPES) OF VEHICLES) INVOLVE0.1Aul mobile Pmkup d1Ulorcycla; ATV boy le, etc.)
.3:GATE OF DEATH .(MOIOay /YC): (Spell .Month)
December 10, 2004
6,'DATE OF BIRTH (MO/Day/Yr)
May 6, 1940
1$b: ADDRESS OF FACILITY
164 N Bridger Ave Pinedale
23 WAS CORONER CONTACTED?
OYES
Approximate interval:
Onset 10 death
25. WAS AN AUTOPSY
PERFORMED
0 YES C.00-
27, DID TOBACC0 USE CONTRIBUTE TO DEATH?
WI YES O O RROBABLV 0 UNKNOWN
29: MANNER OF DEATH
ca Natural.
`O Accident
0 Suicide.
0 Homicide
Pending tnsestoation
O.Could not be d 1 tuned.
33. INJURY AT WORK
OYES NO
36. DESCRIB
HOW INJURY OCCURRED, AND IF TRANSPORTATION INJURY, T
37a CERT ER (Check only one)
PHYSICIAN To the best of my knowledge, death occurred at the time, date 'and Mac, an00ue to the =IMO) and 1 tated,
0 CORONER On the Oasis of examination, aryl y n, in my op ■nl00 death occurred at the arm flatland ptace, Mid d ib the c
Signature of Cart (ter s
e(s) an6 staled.
37c. NAME. TITLE AND ADDRESS OF CERTIFIER (Type pnht)
R v rj J3 (.4c rna-f'F I7?. D_ 17 W' 3rd.' St. Marbleton, WY
.986. DATE RECEIVED BY R STRAR (M9/ ay/Yr)
This is a true and exact reproduction of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.
DATE ISSUED:
This copy, is not valid unless prepared on paper with an engraved border displaying thedate,: seal and signature of the Deputy State Registrar
am a BaraalaN t Coa�T4�
_ti �s81.r,; 4..4dd4 ,t.o.� X462
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
2 0 fl :'F,
STATE FILE NUMBER
Lucinda McCaffrey
Deputy State Registrar
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