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Home My WebLink About968421RECEIVED 12/10/2012 at 12:55 PM RECEIVING 968421 BOOK: 800 PAGE: 296 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY STATE OF WYOMING SS. COUNTY OF LINCOLN I, THOMAS M. BAKER, being duly sworn under oath, state as follows: 1. That Darlene B. Pedersen had joint tenancy with full rights of survivorship with me in land in Lincoln County, Wyoming, more particularly described in the Warranty Deed that was recorded in the Lincoln County, Wyoming land records in Book 630 at Page 6 on August 11, 2006 as Instrument No. 921208. Attached hereto is a copy of that Warranty Deed. 2. That Darlene B. Pedersen died on August 8, 2012. Attached hereto is an original copy of the Certificate of Death issued for Darlene B. Pedersen. 3. That pursuant to Wyoming Statutes 2 -9 -102, I certify that the joint tenancy of Darlene B. Pedersen has been terminated by her death and that title to the above referenced land is now in the name of Thomas M. Baker, a single man. DATED this 0-4 day of December, 2012. ACKNOWLEDGED, SUBSCRIBED AND SWORN TO before me on this 6 day of December, 2012 by THOMAS M. BAKER. WITNESS my hand and official seal. M KEVIN VOYLES NOTARY PUBLIC County of j; State of Lincoln r Wyoming My Commission Expires: July 16, 2015 AFFIDAVIT OF SURVIVORSHIP My Commission expires: 07 /4 THOMAS M. BA R 0029r, RUG -04 -2006 1338 RMT I R 0UPL I TY REALTY WITNESS our hand this day of Slate of County of Witness my hand and official seal. My Commission Expires: Wo ol 1 307 877 3300 P.06 Warranty Deed Steven Tucker and Diana Tucker As jointtenpnts Grantors, for and in consideration of TEN ($10.00) DOLLARS and other Good and Valuable Considerations in hand paid, receipt whereof is hereby acknowledged, CONVEY AND WARRANT TO: Thomas M. Baker and Darlene B. Pedersen As joint tenants with full rights of survivorship Grantees, whose mailing address is PO Box 927, Thayne, WY 83127, the following described real estate situate in Lincoln County and State of Wyoming hereby releasing and waiving all rights under and by virtue of the homestead exemption laws of the State to -wit: Lot 58 of Stewart Country Club Estates Phase 2, Lincoln County, Wyoming ap described on the official plat thereof Subject to any easements, reservations, restrictions or right -of -ways of record, of sight or in use. 2006. Steven'Tucker^ Diana Tuckei The foregoing instrument was acknowledged before me, a notary public_ in and said County and State, by Steven Tucker and Diana Tucker, this 4.-W.--day of 2006. RECEIVED 8/11/2006 at 2:57 PM RECEIVING 921208 BOOK: 630 PAGE: 6 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY 000006 I. CERTIFICATION OF VITAL RECORD TYPE OR PRINT IN PERMANENT S8.8CK INK bo Not USE FELT T)PPEN l FP. 1002RUCTDNa 508 11ANOBOOKa '1F 0E4114 WAB. OUETO OTNEN T006 NATURAL CAUSES. THE CORONER MUST COMPLETE ANO SIGN n11E ..CERTIFICATE DISPOSITION PLACE OF DEATH DATE OF DEATH CAUSE OF DEATH ITEMS 32.38 TO DE USED FOR EXTERNAL CAUSES ONLY I Ct7RONLlt1 1.DECEDENTS LEGAL NAME (Include AKA's 11 any) (First, Middle.lasl. SOW DARLENE BEVERLY PEDERSEN 4 DO 0.. ACE -0- Leal Birthday db.UNOER 1 YEAR :dC. UNDER 1 DAY 5. DATE OF BIRTH (MolDay/Yr) Months Days Hours Minutes 12/14/1934 m F 7 RESIDENCE STATE OR FOREIGN COUNTRY 17b. COUNTY WYOMING LINCOLN 2 STREET NUMBER: "723 COUNTRY CLUB WAY N 6. MARITAL STATUS AT TIME OF DEATH 0 C IX Married Marred, but separated Widowed Divorced Never marred Unknown 10 EVER IN 11a. FATHER'S NAME (Firs(:.Mlddle, Lasl, 5u%) •C ARMED: PORCESP ROY PRENTISS 0 YR.' 128, MOTHER'S MAIDEN NAME (7iro, Middle. Last, SulSo) o MO ELIZABETH MILLER L2 13a. INFORMANTS' NAME (Tyne or print) Z THOMAS BAKER 1d METHOD OF DISPOSITION 2 Bunal.. Cremation a Do align Entombment 0 Re Val horn Idaho Olh (Speclly) 15. PLACE OF DISPOSmON (Name and address of crernalory. other place) EAGLE ROCK CREMATORY 273 NORTH RIDGE AVENUE, IDAHO FALLS, IDAHO 83402 SIGNATURE OF FUNERAL SERVICE LICENSEE OR PERSON ACTING AS SUCH ELECTRONICALLY FILED: BRIAN :J. WOOD 2. SEX :'6, SOCIAI n_TURITY NUMBER.', FEMALE 8 BIRTHPLACE (Ciy and Slate. Territory or Foreign CC/dolly) 'VAN NUYS', CALIFORNIA 7e. CITY OR TOWN T.HAY.NE T.. APT: NO, T1. ZIP CODE.: 7g. INSIDE CIT'. '63127:: LIMITS? Yes ®f S. SURVIVING SPOUSE'S NAME' (II wile. grve;maiden name) THOMAS'M .'BAKER tab BIRTHPLACE (51216, Tenilory, or Foreign Country) OKLAHOMA 12b, BIRTHPLACE.(Slale, Temlory ar Foreign Country) TEN NESSEE OIL RELATIONSHIP TO DECEDENT 13c, MAILING ADDRESS (Slreel and Nu bei City, :Slate Zip Code) HUSBAND P.O. BOX 927'THAYNE, WY 83127 cemetery, 16. NAME AND COMPLETE' :4DD0.E55'OFFUNERAL FACILITY WOOD FUNERAL HOME 273 NORTH RIDGE AVENUE IDAHO FALLS, IDAHO 83402: 17b_UCENSE NUMBER (Orlicensee) CONTACTED.: oueTO CAUSE OF DEATH? M1103 PLACE OF DEATH (19.22(.. URRED SOMEWHERE OTHER THAN A HOSPITAL,:.;' 5 Nursing home/Long term rare lacilily 6 ❑Decedent's home 70 Other (Specify) 21 CITY, TOWN, OR LOCATION OF DEATH, AND ZIP CODE COUNTY OF DEATH IDAHO FALLS, lb 83404 BONNEVILLE OF DEATH ;25, bATE PRONOUNCED DEAD (MO /DeyM)ISpell month) 26. TIME PRONOUNCED DEAD I2annl 11:04 August 8, 2012 11:04 App .Ip,,Inleroal:. Onsel to Death IMMEDIATE CAUSE (Final ACUTE 'RESPIRATORY FAILURE .dl a icondhlon 3 WEEKS Fie6 Ring In.dealh) DUE TO Of a9 a doesaquence o0: E Sequentially list codilions.. n ACUTE RESPIRATORYDISTRESS� i: WEEKS 192. IF DEATH OCCURRED IN A HOSPITAL:. 19b. IF DEATH OCC 1® Inpalienl 2 ❑ER /Outpatient 3 ❑DOA d ['Hospice facility 20.F ACILIN�NAME (Ir pgj ,IaUliry gNe street 084 number) EASTERN IDAHO REGIONAL MEDICAL CENTER 24. TIME 23 O/D DATE OF.DEATH (MayrYr) (Spell month) August 8, 2012 27. CAUSE OF DEATH PART I, Enter the chain n) evenle disease,, injures, or complloations -Ihal directly caused the death.DO NOT enter (retinal eve l6 sue, as cardiac arrest, respiratory arrest, or ventricular libdllalion w'houl showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line: y. it any. leading to the Cause DUE TO (or as a Od equende of): O listed ,n the •6 UNOERLYINGCAUSE p NEUROMUSCULAR WEAKNESS LAST (disease or Injury DUE TO (or as a consb:uence NM Initialed the events i resugirq In death) d PANCREATITIS FART II. S nier other sionincani Condit10ns contributing to de9118 6M not resulting pin the underlying cause given in Pad I 26 WAS AN AUTOPSY 26b. WE' RE AUTOPSY FINDINGS' C CEREBROVASCULAR ACI N PERFORMED? AVAILABLE TO COMPLETE SCDET: DEMENTI SEPSIS THE CAUSE of DEATH? :,3 29 DID TOBACCOUSE 30, IF FEMALE (Aged: 10.544/ Yes., el No 0 Yes 0 No CONTRIBUTE TO DEATH? Not pregnant I year Nol pregnant. bit Oregnenl43 days 31. MANHER'Ljr DEATH y wlhln opal a 0 Yes 0 Probably ;Pregnant al lime 01'dea111' b 1 Year death' E EI: Natural 0 Homicide O 22 No Unknown within 42 days of death year 0' Su1CIde Cfiuld no( be dale(ipined 3 WEEKS 3: WEEKa 32: DATE.OF INJURY (MO/Day/Yr) 33. TIME OF INJURY 34. PLACE OF INJURY (Decedent's home. lane. sliest, construction site, 35. INJURY'AT WORN? (Seab,m4nin).. (Nth/ nursing home. restaurant forest etc.) ❑Yes 0 N F 38, LOCATION OF INJURY:.. 5late City/ Town or County .Zio Code W 3),..) and N be or Localon Aoadmenl Nu nber HOW 1 37, DESCRIBE OW VEHICLE OCCURRED. IF TRANSPORTATION INJURY, BTATE THE TYPES(S) OF VEHICLE(S),INV.OLVEO(Aummabile, pKk o molorryct AN, bigcle: Ic.) SPECIFY WHICH VEHICLE DECEDENN T OCCUPIED. R applicable TRANSPORTATION SBA WAS DECEDENT: ❑Diver /Oparelor Passanpar i7ab, WHAT SAFETY DEVICESISy CO DID DECEDENT USEIEMPV? INJURY ONLY ;Pedestrian ❑Other (Specify) Seel bell y Child safely seal Hairnet ❑Air beg ❑None ❑Unknown 364..CERTIFIER 1Cha01 only one: based on 0)44.14) capacity for Ihis.Cediloale) I$,PHYSIGIAN PHY5ICIAN'655ISTANT:, ❑'ADVANCED,PRACTICE PROFESSIONAL NURSE 7 the best of my knowledge. death occurred allhe lime, dole and place: and due: to the !kLUra/ caus2(s)nmanner staled. CORONER On the basic f esagl nation andlor Investigation. In my oomlo 'deathaCCUrred at Ire bete; dale and place. and due to the cause(s) 396, 06114 SIGNED, and manner staled.' g'�: I 14::a 2012:: Signature and TIDe of 9,4)0., DOUGLAS N. WHATMORE, M.D.' •MM DD' YYYY: 390 NAME, ADDRESS. AND ZIP CODE OF CERTIFIER (Typo or p64) DOUGLAS Ni WHATMORE, 3200'CHANNING' WAY IDAHO FALLS, ID 83404 391. LICENSE NUMBER M 408, REGISTRAR'S SIGNATURE 40b. DATE SIGNED A /_.1,5_/ 9012 DD 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. DATE ISSUED: A This copy not valid unless prepared on engraved border displaying state seal and signature of the Registrar. PBNCO (RSV N%12 STATE OF ;IDAI-JO IDAHO DEPARTMENT OF HEALTH AND'VVELFARE BUREAU OF VITAL 'RECORDS AND HEALTH STATISTICS State of Idaho CERTIFICATE OF DEATH ovi moot. epi:t1reorvn,snsrt;M:7w win, nrEOErrq.iN,nor«EwLrelxowEl'":. LOra) Rs W rrp ewplRCEpx,aso4m wxpEV N.I•rin �aP FxPPx.IPM,pcppE g NO. IAMES B' AYDELOTTE STATE REGISTRAR: `0 0 0 )0 1 /4\■%\i111t 111 ALI ID LID ID V LI ID L 1 ll1 WON MIN IVMuJ I- u It i3 1111 11 LU!