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Home My WebLink About968233When recorded mail to: Jerene N. Curtis 1180 Hubbard PL Saint George, UT 84790 -6807 AFFIDAVIT AND ACCEPTANCE OF TRUSTEESHIP Comes now the undersigned Jerene N. Curtis, 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, Raymond F. Curtis 3. That said deceased is one in the same person as Raymond F. Curtis listed in that certain document as recorded on May 27, 1992 at Entry No. 748889 in Book 310PR at Page 504 in the office of the Lincoln County recorder, State of WY. 4. That the purpose of this affidavit is for Jerene N. Curtis to accept the Trusteeship of the RIJ Curtis Family Trust, Raymond F. Curtis and Jerene N. Curtis, Trustees AKA Raymond F. Curtis and Jerene N. Curtis, Trustees of the R/J Curtis Family Trust dated April 21, 1992 and hereby agree to act as Trustee of said Trust on all the terms, provisions and conditions specified in said Trust. 5. That an Original death certificate of the deceased is hereby attached. Legal description: ALL OF LOT 103 OF THE STAR VALLEY RANCH PLAT 18, LOCATED IN LINCOLN COUNTY, WYOMING, FILED MAY 3, 1979 AS INSTRUMENT NO. 523540 IN THE OFFICE OF THE LINCOLN COUNTY CLERK. State of WY County of Lincoln ss: On 16 day of November, 2012personally appeared before me Jerene N. Curtis, Trustee of the RIJ Curtis Family Trust AKA Raymond F. Curtis and Jerene N. Curtis, Trustees of the R/J Curtis Family Trust dated April 21, 1992 and the signer(s) of the within instrument, who duly acknowledged to me that she executed the same. Dyanna Parker Notary Public County of 1'' State of Lincoln =1. Wyoming My Commission Ex Tres RECEIVED 11/29/2012 at 4:59 PM RECEIVING 968233 BOOK: 799 PAGE: 366 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY 1 rene N. Curtis, Trustee A DECEDENT 1. NAME OF DECEDENT FIRST MIDDLE, LAST Raymond Frederick. CURTIS 2. SEX Male 3a. DATE OF DEATH (Mo., Day, Yr.) November 19 2003 3b. TIME OF DEATH (24 hr. clock) 609 4. DATE OF BIRTH (Mo., Day, Yr.) 15. July 12, 1925 AGE Last Birthday 78; IF UNDER 1 YEAR IF UNDER 24 090. 6. BIRTHPLACE Deseret, 6b. NAME OF (i/ outside University (City State or Foreign Country) 17. SOCIAL SECURITY NUMBER Utah j- montns usys Hours mmu es Bi. PLACE 1 HOSPITAL (status codes for Nosptal only): ALL OTHER LOCATIONS: OF DEATH IX r, (check only 1. Inpatien I U. 5. Nursing Home Ej 6. Residence (any) one) P] 2. ER/Outpatient O3. DOA 1 7.Other(specify) HOSPITAL, NURSING HOME OR OTHER FACILITY a te testify give street address o/ location) Hospital SPOUSE (if wife, give maiden name) Jerene Nelson sc. CITY, TOWN, OR LOCATION OF DEATH Salt Lake City, 8p. COUNTY OF DEATH Salt Lake 9. SURVIVING 10. WAS DECEDENT EVER IN THE U.S. ARMED FORCES? J 1. Yes 17 2. No 11. MARITAL STATUS Ill 9 Never Married 3. Widowed I 122. Married 0 4. Divorced 12a. DECEDENTS USUAL OCCUPATION (Give kind of work done during most 07 working tile. Do NOT enter retired) Merchant 12b. KIND OF BUSINESS OR INDUSTRY Department Store 13a. RESIDENCE STREET AND NUMBER; 1180 Hubbard Place 13b. CITY, TOWN OR COMMUNITY St. George 13c. COUNTY Washington 13d. STATE Utah 13e. INSIDE CITY LIMITS? r }C 1. Yes u 2. No 113f. 21P CODE 114. WAS 'DECEDENT OF HISPANIC ORIGIN? 1. Yes 2. No litre!, Slfed 84 790 "i. Mexican II z. Cuban I J 3. Puerto Rican 4. Other (Specify) 15. RACE Black, White, Am. (tribe may ay be entered), Indian Japanese, etc. (Specify) Caucasian 16. EDUCATION (speciry only highest gred) Elementary or Secondary (0.12-12) College (13.16 or 17 12. PARENTS 17. FATHERS NAME (First, Middle, Last) Lyman R. Curtis. 18. MAIDEN NAME OF MOTHER (First, Middle, Last) Ines Western INFORMANT 19. NAME, RELATIONSHIP AND MAILING,ADDRESS OF INFORMANT W IFE: Jerene N. Curtis +1180 Hubbard Place St. "George, Utah 84790 DISPOSITION 20. METHOD OF DISPOSITION 1 EnlombmenlL 2. Donation 3.OItter 5L] 4. Burial J5. Cremalion0 6. Removal 21a. DATE °OF DISPOSITION Nov. 22, 2003 21b. PLACE OF DISPOSITION (name of cemetery crematory, or other place) Salem City Cemetery LOCATION City or Town, Slate Salem, Utah 22 N URE OF FUNERA ERVICE LICENSEE 23. LICENSEE NUMBER 95- 270363 24. FUNERAL HOME (Name and address) Larkin Mortuary CERTIFIER Al NDED iL7iy *-TIF/MG PHYSICIAN November 19 2003 i f n icon ee hurls e noumfene s death reported to M.E.7 1. Yes U 2. No M.E CASENO. HR. YEAR 260 E. South Temple SLC Utah 84111 27a. CERTIFIER I I 1. CERTIFYING PHYSICIAN To the;besl _MO_DAY of my knowledge, death occurred at the lime, dale, and place, and due to the cause(s) and manner as stated. 1 2. MEDICAL EXAMINERILAW ENFORCEMENT OFFICIAL: On the basis of examination and/or investigation, in my opinion, death occurred at the time, date, place and due to the cause(s) and manner as.slated. 27b. 51G TORE AND TI OF CER FIER s 27a LICENSE NUMBER 6 z.0s l 27d. DAT SIGN D (Month, Day, Year) l r SIGN it 28. NAM ND ADDRESS DDRESS OF PERSON WHO CERTIFIED THE CAUSE OF DEATH (Item 31) (Type/Print) Wolframe E., Samlows.ki_M.D. 50 North Medical Drive Salt Lake City, Utah 84132 29. TRAR'S SIRE I30a. DATE REGISTRAR NOTIFIED OF DEATH (Mo., Day, Yr.) 305. DATE FILED (MO., Day, Yr,) November 25, 2003 CAUSE OF DEATH UDH -BVR Form 12, Rev. 12/98 31. PART I. ENTER THE DIS INJURIES OR COMPLICATIONS THAT CAUSED THE DEATH. DO NOT ENTER THE MODE OF DYING, SUCH AS CARDIAC 1 Approximate Interval OR RESPIRATOR REST, SHOCK. OR HEART FAILURE. LIST ONLY ONE CAUSE ON EACH LINE. 1 Between Onset and Death. IMMEDIATE CAUSE (Final l disease or condition resulting a.. LJ■ f i a4 yr- I.� o� 6 C, CONSEQUENCE death) DUE TO (oR AS A CONSEQUENCE OF) b. Sequentially list di If ON El) E 0( DUE R A C NCE Of OF any, leading to immediate 12 C. OF): cause. Enter UNDERLYING c C: -t 1 7 CAUSE (disease or Injury that DUE TO (OR AS S A (OR A CO SEQUENCE OF): initiated events resulting in death) LAST d... PART II. Other Significant Conditions contribUting to death' but not resulting in the underlying cause given In Part I 32. IN YOUR OPINION, TOBACCO USE BY THE DECEDENT: 1. Probably eonlnbuted to the cause of death. II 5. NON USER 22 Was the underlying cause of death. 33a. WAS AN AUTOPSY PERFORMED? t. fj 1. Yes NI 2. No 33b. WERE AUTOPSY FINDINGS AVAILABLE PRIOR TO COMPLETION OF CAUSE OF DEATH I5e. Yes EJ 2. No 41 hityJ ome, /arm, street, factory, �E D¢rJ. Did not contribute to the cause of death. 6" IF K 4. Is unknown in elation to the cause of death. 34. MANNER OF DEATH 1. Natural ill 2. Accident "1 3. Suicide I-I r 4. Homicide 5, Undetermined fl6:Peeing If injured Investigation Purposely or Accidently 35a. DATE OF INJURY (Mo., Day, Yr.) INJURY 35b. T( 24 IME Hou OF r Cock) 35c. INJURY AT WORK? 1. Yes 2. No 35d. PLACE /fice, buiM OF irrg INJ, Uetc. RY spec o 35e. LOCATION (Street or rural route number, city or town, county and state.) 35f. If motor vehicle accident specify 1 decedent was driver, passenger or pedestrian. 35g DESCRIBE HOW INJURY OCCURRED enter sequence of events which resulted in NATURE OF INJURY should be entered in item 31) injury, V County Access to 1 f rmeeon on Ihts form Is issued under the Veal Statistics Act ens Rules. LOCAL FILE NUMBER 18 -53 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 section 26 -2 -22 of the Utah Code Annotated, 1953 As Amended. Date issuedl 25 SALT LAKE 2003 STATE OF UTAH DEPARTMENT OF HEALTH CERTIFICATE OF DEATH 13azil.ty Aa-yur STATE FILE NUMBER 03 Barry E. Nangle r g DIRECTOR OF VITAL RECORDS II II III II III I I I II t„ 11.01330159 0 1 3 3 0 1 5 9* 8 Tr G S aI• I s ANY ALTERAT OR ERASURE VOIDS THI CERT k i t i no�t1