HomeMy WebLinkAbout968498AFFIDAVIT OF SURVIVORSHIP
RECEIVED 12/13/2012 at 11:19 AM
RECEIVING 968498
BOOK: 800 PAGE: 555
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, EDWARD J. CARLSON, being of legal age and first duly sworn, deposes and says as follows:
STATE OF WYOMING
COUNTY OF LINCOLN
ss.
1. That Monte Lee Rochford, the decedent mentioned in the attached certified copy of the certificate
of death, is the same person as Monte Lee Rochford named as one of the parties in that certain
Quitclaim Deed dated October 15, 2008, executed by Monte Lee Rochford and Vivian Rochford,
f /Ida Vivian White, husband and wife to Monte Lee Rochford and Vivian Rochford, husband and
wife as tenants by the entireties, recorded as Receiving No. 942873, on October 15, 2008, in Book
707 at Page 55, of the Official Records of Lincoln County, State of Wyoming, concerning the real
property situated in the County of Lincoln, State of Wyoming and described as follows:
Lot 4 of Block 55 of the Second Addition to the Town of Kemmerer,
Lincoln County, Wyoming as described on the official plat thereof.
2. That the personal property owned by Monte Lee Rochford is as follows:
a. 2003 Ford Pickup; VIN #1FTRX18L03NB85441
3. That I am the brother -in -law of Monte Lee Rochford and the brother and an heir of Vivian Rochford,
f /Ida Vivian White and thereby am a person interested in the effective property or the title thereto
and pursuant to 2 -9 -102 W.S. (1980) hereby make the death a matter of record and certify that
upon the death of Monte Lee Rochford, his previous estate in the property was terminated.
4. That the certified copy of the certificate of death indicates that Monte Lee Rochford died on August
16, 2012 in Holladay, Salt Lake County, Utah.
Dated this 15 day of December, 2012.
STATE OF WYOMING
ss.
COUNTY OF LINCOLN
This Affidavit of Survivorship was subscribed and sworn to before me by Edward J. Carlson, this
3 Lh day of December, 2012.
DMA A. f NSEN-WakYJ r'
=WY OF i Mil OF
UNCOLN ITiOralG
NY COMMISSION EXPIRES 3
Osiot
EDW i J. CARLSON
/J/o11n/i. C L. /l'2�Y11SP�v�/
NOTARY PUBLIC
My Commission Expires: 3/2 9/40. /5
0055
Date of Death:
City of Death:
Age;
CERTIFICATION OF VITAL RECORD
a_
DECEDENTINFORMATION
Place of Birth:
ArmedServics;
Spouse's Name
fndustry/ usinesS
Residence:
Mother's Name:
Facility or Address:_._
DISPOSITION INFORMATION
Method of Disposition Crem=ation 1
:Place bf DispesAii* Ufatf iTIOV Dlrectgs_C
Date of Disposition- -fly t 2 20,12
FUNERAL HOME 5
Funer61 Home: Crandall Funera %Ho me
Address: PO Boxi6, 105(East Center Street
Funeral Director: Williaml,W Ball
EDIC-AL CERT'IFI i TI
Medrel Professional;
tk;
CAUSE OFDEATH
Stage IV Prostate Career
Other significant cohditi0,ns: Obstructive Kidney Failure, Senile Dementia
Tobacco Use: Probabl =j Contributed
Medical Exami2t`GontactecTYes° �utapytPerformed� Mar o
Date Registered: August 20,2012
Date Issued: September 27, 2012
CERTIFICATE OF DEATH
State Eile Number 2012049,:9
Time of Death: 13:10
County of Death: Salt Lake
Date=bf Btr h Augtasf20
Se�
MarEKST
Usua upa i
Education:
Father's Name:
Facility Type:
Married
Go mmariiea LO
High chool or GED
Ira R Rochford
Nursing Home /Assisted Living
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wi✓ &9e MIL UNre
This is an exacLreproduction of the:-doeorgent reg_isterect=ir ttr State Office MatistitSI.
Sectilrity faatures of this offi ialtdocurhent uclude r fgg_i Bd er, R�rDs isin top _cycloi�ls
ultra violet fibers and hologram image df the• Utah St atSSealr er thltn ordL STafe o Dfah" "(hie_
document displays the date, s -and signature Stat i the CountyLDlsttict Health Officer.
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DirectoC /HeafthiQficer-
CouritylDis fcrIHealth_Repartme
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