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Home My WebLink About968019WITNESS my hand and official seal. RECEIVED 11/16/2012 at 4:18 PM RECEIVING 968019 BOOK: 798 PAGE: 380 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY Affidavit of Survivorship I, Dolly L. Scott, being of lawful age and duly sworn according to law, upon my oath, depose and state: That under the date of August 25, 2000, for valuable consideration, Margaret Weatherston, also known as Margaret E. Weatherston, by deed of that date, which deed was duly filed of record in the Office of the Lincoln County Clerk, on September 6, 2000, in Book 451PR, Page 55o, conveyed to Bobby H. Scott and Dolly L. Scott, as joint tenants with full rights of survivorship, the following described land, in the County of Lincoln, State of Wyoming, to -wit: Lot 354 in Star Valley Ranch RV Park Plat 1, as platted and recorded in the official records of Lincoln County, Wyoming That by reason of said conveyance aforesaid, the said Bobby H. Scott and Dolly L. Scott, as joint tenants with full rights of survivorship, 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 Bobby H. Scott, on the 23rd day of April, 2005. That by reason of and upon the death of Bobby H. Scott, title in the above described real property vested in Dolly L. Scott. Affiant avers and certifies that Bobby H. Scott, is the identical party named with Dolly L. Scott 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 1 q day of N0rfoil:kr 2012. My Commission Expires: 1' l0'kf a- ?--.7 Z fl State of V1,4i*' II ss. W County of o41 Subscribed and sworn to before me, a notary public in and for said County and State, by Dolly L. Scott, this N day of IN) WOW 2012. X3 0 NOTA iY PUBUO JERMAINE ODJEGBA 807989 COMMISSION EXPIRES MARCH 28, 2016 STATE OF UTAH 1 t r;' i' u Aceea t o 1pforma0on on 1105 lo,m Is Ilmilae antler 1neVIM181,101108 Act sna mew LOCAL FILE NUMBER DECEDENT PARENTS INFORMANT DISPOSITION CERTIFIER CAUSE OF DEATH RACE AND EDUCATION UDOH -OVRS Form 12 Rev. 11/30104 REGISTRAR 5. WAS' DECEDENT EVER IN THE U.S. ARMED FORCES? ®1. Yes. 2. No a 7 -a3ti 1. DECEDENTS LEGAL NAME (In tide AKA'a,if any)(Fkst,Middle Last Bobby H. Scott Mo,; Day, Yr. IF UNDER 24 HRS. 4, DATE OF BIRTH Y March 5, 1931 5. AGE Lest BalhdaY (Years) *7 4 Bb, NAME OF HOSPITAL, NURSING HOME OR OTHER FACILITY(Ifoutside a faciRY, give street address of location) Dixie Regional Medical Center 128. DECEDENTS. USUAL OCCUPATION (Glee Mnd of work done daring most of working life. (7o'NO2 enter Mired. Post Office Clerk 13b. STATE Utah 17. METHOD OF DISPOSITION 01,E01omGMM 1 Other 5 cremation 2. Donegan g 4.6udal e. Removal 21, -sin car' URE OF FUNERAL SERVICE LIICEN EE SIGNATURE TITLE OF CERTIFIER 298. DATE OF "INJURY(Mo., Day, S, 13C. COUNTY Washington, 14. FATHER'S NAME (First, Middle, Last).; Bryan Scott 18c LOCATION OF DISPOSITION •C4yot 11Wrf,Btale Hurricane,`UTtah ERTIPIER (Check only 1 CERTIFYING PHYSICIAN. To the bawl of my'knoWled 2. MEDICAL EXAMINER: On the beet's' q inetion M.E. Case No. PART IL Ogler significant Conditions contributing to death but notresultingln the underlying cause given in Pan 1 26. IN YOUR OPINION, TOBACCO USE"BY THE DECEDENT: 1. Probably oonblbuted to the caused death. 2. Was t underlying cause 00 death, I] 8, UNKNOWN 3. Did not contribute tithe cause o*,daelh, /FUSER 4, Is unknown in relation to the Celia.) Of d 0811 5, NONUSER 25b..TIME OFINJURY (24 hF,Clock) 29f. LOCATION(SIteet route number,'oiydytown, 99Ony andst8te) IF UNDER 1 YEAR Months %MARITAL STATUS LJ L Never Married 2. Marred 3 Widowed 5. Mooed, but separated 4. Divorced 6. UnWgwn 30. WAS DECEDENT OF HISPANIC ORIGIN? (06.0) 144. boy waeceaNls 0ol SgMWNlspsnkt44oJ I. Yes ®2.: p(yes, Check Me bag Mal bell describes whether the deeaaenl b6p80o10Hl8penkAlulro... 1. Yes, Meelan, Meelcan American, 0903800 2. Vex Cuban 3. Yes, Puerto Rican 4. Yes, other SpanahMapenhlla0eo (s Days Notss Minutes 12b. KIND BUSINESS OR INDUSTRY U S. Government 18e. DATE OF DISPOSITION April 24, 2005 19. LICENSEE NUMBER 112551 29c. INJURY AT WORK? T. :Yes 2. No 2. SEX Male 6. BIRTHPLACE (City 6 State or Foreign Country) Malta, Idaho ea. PLACE OF DEATH (Cheek only one) IF DEATH OCCURRED IN A HOSPITAL I IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL: 1. Inpatient 2. Eft/Outpatient 8, DOA 5. Nursing Home/Long lean care facility 6, Decedent's Home 7. Other (spesiy) 8c. COUNTY OF DEATH Washington 23a. NAME, ADDRESS AND: ZIP CODE Fe'PE' ON WH0, CERTIFIEDTHE CAUSE OF DEATH (Item 24) (TypetPnnt) Gregory D. Price, M.D. 736 S. 900 E., Suite #108, St. George, UT 84790 38. DATE OF DEATH (Mo., Day, St) April 23, 2005 13d. CITY, TOWN, COMMUNITY, OR RURAL Washington 3b 74 hr °Clo x) TH" 1321 7. SOCIAL SECURITY NUMBER'J Ed. CITY, TOWN OR LOCATION OF DEATH St. George 11. SURVIVING SPOUSE'S NAME Of wife, give name priori° first marriage) Dolly Mihlberger 138. RESIDENCE STREET AND NUMBER 504 E. Telegraph St. #9 15. MOTHER'S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last) Margaret Ellen Hadfield 16. NAME, RELATIONSHIP. AND MAILINGAADORESE,F," INFORMANT: 6 Number, Ciy, Stela. Zip) Dolly Scott -Wife 504 E. Telegraph St. #9 Washington, Utah 84780 13e. ZIP CODE" 84780 13f INSIDE CITY LIMITS?'. IE 14 Yea 2. No; 18b. PLACE OF DISPOSITION (name of cemetery, crematory, or other place) Options Cremation 20. FUNERAL HOME (Name and complete address) Spilsbury Mortuary 110 South. Bluff St. St. George, Utah 84770 -3333 LIC. No. 184689 22e. Was Medical :Examin Contacted? ddeath:occurred al the time, date, and place, and due to the ceuse(8) and manner as stated. 1. Yes IW 2. NO I, In, In my opinion, death occurred at the lime, date, place and due to the causes(s) and manner as slated DATE SIGNED 23b. DATE DECEASED WA LAST ATTENDED BY HYSI IAN cardiac arrest, respiratory I A 00 pfbximate lnterva( 1100,0 n set e nd r ,f7 24. PART I. Enter the chain Of eventsdiseasas m1111`1es %or cap�l8%00ns that directly caused the death. DO NOT enter terminal events such as card T ABBREVIATE Enter only one Cause on a line, alresLorvenelwlare Iletionwi the4liol IMMEDIATE CAUSE (Final a. QIL: dlaease or condition 0f{AS AooNsvou resulting In death) b /e 0 V) Sequentially list conditions, If n AS A C NSEQUENCE 0 any, leading to the cause listed on line a. Enter the c UNDERLYING CAUSE (0180x30 DUE TOi(ORASA CONSEQUENCE OF): or Injury that Initiated events resu ting In Castes) LAST OF): id quo( 17.1x1 N NER tar DEATH I 1. Natural 3. Suicide 5. Could not be Determined 2. Accident 4. Homicide 6. Pending Invesligagon 25a. WAS AN AUTOPSY PERFORMED? 1.Yes 2, No 29d. PLACE OF INJURY -At home, arm, street, factory, office, building, etc. (Specify) 31: DECEDENT'S RACE (Chatham or mare races to Indicate Mantle MoaWnf coaHeed himself aham? fo be) ®01.. 02. Black or African Amedoan 03. American Indian or Alaska NelNe (Name of the en1011ed or pdo1p0l lobe) O4. Chinese os. N01Ne Hawaiian ❑Os+. Other Asian (Specify) 0 10. Asian Indian 0 12, Samoan 14. Guamanian orChemomo 15. Other Pacific Islander (Specify) 00. Other (Specify) 05. Japanese 07. Filipino 11. Korean 13. Vietnamese 25b. WERE AUTOPSY FINDINGS AVAILABLE' PRIOR TO COMPLETION OF CAUSE OF DEATH? 28. IF FEMALE 1. Not pregnant within past year 2. Pregnant at time of death 3. Not pregnant, but pregnant within 42 days of death 4. Not pregnant, but pregnant 43 days to 1 y081 r befourdealhl. 5. Unknown If pregnant within the past year 9e. If motor vs+ Isle accident. 1. Driver 2. Passenger 3, PedpSUlall 4. Other 5. Unknovm 25g.- DESCRIBE HOW INJURY OCCURRED (enter sequence of events which resulted in injury, NATURE OF INJURY Shquld be entered in item 24) 32 DECEDENTS EDUCATION (Check Me box MN best describes the highest degree or In of school completed at Me Ilme ordeath., 1. elh grade or less 2. Wes -1291 grade: no diploma 3. High School graduals+ orGEO cempleled 4. Some college aedll, but no degree 5. Associate degree (e.3., AA; AS) B. Bachelors Degree (e.g., BA, Aa, ES) 7. Mangoes degree (0.0., MA, MS, MEng, MEd, MSW, MBA) 8. Doctorate (8.0., PhD, Edo) or Professional degree (e.0. Mb, DOS, DVM, LLB, JD) 34 DATE FILED APR 2 0 110, This is to certify that this is a true copy of the certificate on file in this office, This certified copy is issued under authority of sectio 2 -22 of the Utah Code Annotated, 1953 As Amended. co urn Date Issued: ",t� Washington LO co >o, (A Barry E. Nangle County a DIRECTOR OF VITAL RECORDS Registrar' LC01696400 it III III 111111111111 L STATE OF UTAH DEPARTMENT OF HEALTH CERTIFICATE OF DEATH STATE FILE NUMBER 003 WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES. ANY ALTERATION OR py,suR E VOIDS THIS CERTIFICATION Y''