HomeMy WebLinkAbout968600STATE OF WYOMING
SS
COUNTY OF LINCOLN
AFFIDAVIT OF SURVIVORSHIP
Donna L. Kelsey, first duly sworn, upon oath, deposes and says:
1. Donna L. Kelsey is the widow of Ronald L. Kelsey and has knowledge of
and is competent to testify concerning the facts as stated below.
2. Donna L. Kelsey and Ronald L. Kelsey were married to each other and
they lived together as husband and wife in Lincoln County, Wyoming continuously until
the death of Ronald L. Kelsey.
3. Donna L. Kelsey and Ronald L. Kelsey owned, as husband and wife joint
tenants with right of survivorship, the following real property:
ALL OF LOT 7 OF THE CORSI RANCHETTES SUBDIVISION, BEING
LOCATED IN LINCOLN COUNTY, WYOMING, FILED APRIL 8, 1981
AS INSTRUMENT #555850 IN THE OFFICE OF THE LINCOLN
COUNTY CLERK, Kemmerer, Wyoming.
Subject to easements, declarations of covenants and restrictions, rights of
way of record, and taxes for the current year and thereafter. (The
"Property
as indicated by the Warranty Deed recorded as Document No. 965460 at Book
789, Page 196 in the Lincoln County, Wyoming Clerk's Office, Kemmerer, Wyoming.
4. On November 28, 2012, Ronald L. Kelsey died in Teton County,
Wyoming Attached is a Certified Copy of his official Death Certificate certified to by
the State of Wyoming, Department of Health.
5. By reason of the death of Ronald L. Kelsey on November 28, 2012, Donna
L. Kelsey became the sole owner of the above described property.
1
RECEIVED 12/20/2012 at 9:34 AM
RECEIVING 968600
BOOK: 801 PAGE: 104
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
0 01.0
DATED: this
day of December, 2012.
Subscribed and sworn to before me by Donna L. Kelsey this /6 day of
December, 2012.
Witness my hand and official seal.
JACK D. EDWARDS NOTARY PUBLIC
COUNTY OF WYOMING STATE OF
s U
MY COMMISSION EXPIRES
My commission expires:
2
00107
Donna L. Kelsey
Jaes
NOTARY PUBLIC
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH 0 1 6
Decedent: State File Number: 2012- 003738
Name: Ronald Lyle Kelsey
Gender: Male Social Security Number:
Date of Birth: September 06, 1944 Age at the Time of Death: 68 years
`Date and Place of Death:
Date of Death: November 28, 2012 County of Death: Teton
City of Death: Jackson
Location: St. Johns Hospital PO Box 428
Additional Decedent Information
Place of Birth: Rock Springs, Wyoming
Residence: Etna, Wyoming
Marital Status: Married Donna Lee Williams
Armed Forces: Yes
Name of Father: Lyle Cole Kelsey
Name of Mother: Gladys Schultz
Informant: Donna Lee Kelsey
Disposition:
(vltthod of Disposition: Cremation
Place of Disposition: Schwab Mortuary Crematory, Afton, Wyoming
Funeral Home or Facility:
Facility: Schwab Mortuary, Afton, Wyoming
Cause of Death:
The immediate cause is listed an the first line followed by any underlying causes:
(a) Respiratory failure
(b) Lung cancer /COPD /pulmonary fibrosis /pulmonary emboli
Other Significant
Conditions:
Manner of Death: Natural Death Time of Death: 00:15 (Actual
Certifier:
Type: Physician
Name: Gerald Katz, M.D.
Address: PO Box 428, Jackson, Wyoming, 83001
Date Filed: December .10, 2012
t'2 669459
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming.
G DATE ISSUED :Tuesday, December 11, 2012
p .1..
i This copy is not valid unless prepared on paper with an engraved border.
Relationship:
Interval:
4 days
20 years
J ames McBride
Deputy State Registrar
e_ R CERTIFICATI VITAL RECORD
w
i