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Home My WebLink About968733When recorded mail to: I. Glenn Perkins 111 Maplewood Avenue Pocatello, ID 83204 AFFIDAVIT AND ACCEPTANCE OF TRUSTEESHIP Comes now the undersigned I. Glenn Perkins 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, Mary D. Perkins 3. That said deceased is one in the same person as Mary D. Perkins listed in that certain document as recorded on December 7, 2006 at Entry No. 925133 in Book 642 at Page 473 in the office of the Lincoln County recorder, State of WY. That the purpose of this affidavit is for I. Glenn Perkins to accept the Trusteeship of the Glen Perkins Family Living Trust dated November 11, 1985 and hereby agree to act as Trustee of said Trust on all the terms, provisions and conditions specified in said Trust. 5. That a Original death certificate of the deceased is hereby attached. Legal description: SAGE TOWNSITE THE FOLLOWING LOTS IN THE TOWNSITE OF SAGE, LINCOLN COUNTY, WYOMING, ACCORDING TO THE OFFICIAL PLAT THEREOF: ALL OF LOTS 1 THROUGH 5 OF BLOCK 1 ALL OF LOTS 1 THROUGH 6 OF BLOCK 2 ALL OF LOTS 1 THROUGH 4 OF BLOCK 3 ALL OF LOTS 1 THROUGH 4 OF BLOCK 4 ALL OF LOTS 1, 2, 4, 5 AND 6 OF BLOCK 5 ALL OF LOTS 1 THROUGH 6 OF BLOCK 6 TOGETHER WITH A PIECE OF LAND ADJOINING THE ALLEY ON THE NORTH SIDE OF LOTS 1 AND 2 OF BLOCK 3, 100 FEET RUNNING EAST AND WEST, THENCE RUNNING NORTH AND JOINING RAILROAD RIGHT -OF -WAY; THIS PIECE OF LAND BEING LOCATED IN THE EXTREME NORTHWEST CORNER OF THENE'/SW'/4 OF SECTION 8, TOWNSHIP 21 NORTH, RANGE 119 WEST OF THE 6TH P.M., LINCOLN COUNTY, WYOMING. SAGE PARCEL THE NW'/4SE '/4; EY2SW1/4; AND THE SW SW% OF SECTION 8, TOWNSHIP 21 NORTH, RANGE 119 WEST OF THE 6TH P.M., LINCOLN COUNTY, WYOMING. LESS AND EXCEPT THAT PORTION THEREOF SURVEYED, PLATTED AND RECORDED AS "JULIAN ADDITION TO SAGE, LINCOLN COUNTY, WYOMING ELLIS PARCEL TOWNSHIP 21 NORTH, RANGE 119 WEST OF THE 6TH P.M., LINCOLN COUNTY, WYOMING: SECTION 8: NE%: NE' /<SE'/ SECTION 9: W%NW'/o; SE' /4NW'/o; SW/ LESS AND EXCEPT THOSE LANDS CONVEYED TO LINCOLN COUNTY IN THAT DEED RECORDED FEBRUARY 10, 1932 IN BOOK 17 ON PAGE 241, IN THE OFFICE OF THE LINCOLN COUNTY CLERK, ALSO LESS AND EXCEPT THOSE LANDS CONVEYED TO LINCOLN COUNTY IN THAT DEED RECORDED FEBRUARY 19, 1932 IN BOOK 17 ON PAGE 249, IN THE OFFICE OF THE LINCOLN COUNTY CLERK. State of 1 cl t i County oTMEIT ss: On December i 2012 personally appeared before me I. Glenn Perkins, Trustee, of the Glen Perkins Family Living Trust, Created by instrument dated November 11, 1985, and the signer(s) of the within instrument, who duly acknowledge J f jpe that They executed same. G Notary Public J L-1. f, ,�OtARr Commission Expires: tir! 1 ig I 01'3 14 %-16t o GEUo� RECEIVED 12/28/2012 at 11:54 AM RECEIVING 968733 BOOK: 801 PAGE: 487 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY Tenn Perkins, Trustee 0Q` 0 1-3- st, ERTIFICATION OF VITAL RECOR D DISPOSITION PLACE CF DEATH DATE OF DEATH ITEMS 32 -38 TO BE USED FOR EXTERNAL CAUSES ONLY (CORONER) 9214.9 1-111 1.DECEDENT'S LEGAL NAME (Include AKA's if any) (First.; Middle, Last. Suffix) 2. SEX t MARY D. PERKINS FEMALE N an O 4a: AGE -Last Birthday 4b.UNDER 1 YEAR 4C. UNDER 1AAY 5. DATE OF BIRTH (MO/Oa /Day/Yr) 6. BIRTHPLACE (City and 51018, Territory, or Foreign Country) Months Days Hours Minutes `G 87 (veers) 08/20/1924 SAGE, WYOMING N 7a. RESIDENCE STATE OR. FOREIGN COUNTRY 7b. COUNTY 7c. CITY OR TOWN.. Lo IDAHO BANNOCK POCATELLO 7d. STREET AND NUMBER 7e- APT, NO. '7t. ZIP CODE 7g. INSIDE CITY LIMITS? 111 MAPLEWOOD AVE N 8. MARITAL STATUS AT TIME OF DEATH u c Memed 0 M med but separ tea Widowed in Divorced Never married El Unknown I. GLENN PERKINS m 10. EVER IN U.S. 11a. FATHER'S NAME (First, Middle. Last, Suffix) ARMED FORCES? THURLOW:W, O'NEILL WYOMING 2, Yes 12, MOTHER'S MAIDEN NAME (First. Middle, Last, Suffix) :121, BIRTHPLACE (State, Territory or Foreign Country) E FRANCIS M. JULIAN 3. SOCIAL SECURITY NUMBER 83204 21 Yes 0 N 9. SURVIVING SPOUSE'S NAME (If wife give maiden name) :11b. BIRTHPLACE (State, Territory or Foreign Country) WYOMING U 13a. INFORMANT'S NAME (Type: or punt) 13b. RELATIONSHIP TO DECEDENT 13, MAILING ADDRESS (Street and Number, City. Stale, Zip Code) Z I. GLENN PERKINS HUSBAND P.O. BOX 683 POCATELLO, ID 83204 Q:. 14. METH OF DISPOSITION. 15. PLACE OF DISPOSITION (Name and address of cemetery,'. 16.: NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY O crematory.: other place) 0 E Donation ID Entombment PORTNEUF VALLEY CREMATORY DOWNARD FUNERAL HOME 0 Removal from Idaho 241 NORTH GARFIELD AVENUE 241 NORTH GARFIELD AVENUE Other SIGNATTUU (Specify) POCATELLO, IDAHO 83204 POCATELLO, IDAHO 83204 97a. 7 '1RE OF FUNERAL SERVICE LICENSEE OR PERSON ACTING AS SUCH '.17b. LICENSE NUMBER ER (0 (Oflicensee) 18. WAS CORONER CONTACTED DUE TO CAUSE OF DEATH? I' ELECTRONICALLY FILED: LANCE R. PECK M0821 Yes 0 No PLACE OF DEATH (19 -22) 19a, IF DEATH. OCCURRED IN A HOSPITAL:; 19b. IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL: 10 Inpatient 2 DER/Outpatient 3000A 4 ❑Hospice tacitly 5 Nursing home /Long term care 1001(ty 600ecedenl's home 70 Other (Specify) 20- FACILITY NAME (It no IaciGty, give street and number).:. 21. CITY. TOWN, OR LOCATION OF DEATH, AND ZIP CODE "22. COUNTY OF DEATH 111 MAPLEWOOD AVE POCATELLO, ID. 83204 BANNOCK 24. TIME OF DEATH 25. DATE PRONOUNCED DEAD (Mo /Day/Yr) (Spell month) 26. TIME PRONOUNCED DEAD (24hr)' 124hr) 20:40 May 17, 2012 20:40 23. DATE OF DEATH (Mo/Day/Yr) (Spell month) May 17, 2012 27. CAUSE OF DEATH. PART. 1-. Enter the chain of events --diseases, itares. or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest. or ventnculat fibrillation without showing the etiology DO NOT ABBREVIATE Enter only one cause on a line IMMEDIATE CAUSE (Final: PNEUMONIA disease or condition resulting in death) DUE TO (or as a consequence oly Approximate Interval: Onset to Death DAYS Sequentiany list conditions. b DEMENTIA YEARS y if an leadin to the cause DUE TO (or as a consequence of) O listed on line a. Enter the UNDERLYING. CAUSE O LAST (disease: or injury j that initiated the events G resulting in death) S 4 P.! PART II:'Enler other 5ianifcan(cnndNnns contributing to death but not resulting in the underlying cause green in Part 28a. WAS OR AUTOPSY -26b. WERE AUTOOPSY Y FINDINGS c PERFORM AVAILABLE TO COMPLETE t THE CAUSE OF DEATH? 29. DID TOBACCO USE 30. IF FEMALE (Aged 1054): Yes 0 No Yes No CONTRIBUTE TO DEATH?' r Nol pregnant within past year 0 pregnant, but 43 days 31. MANNER OF DEATH Yes Probably Pregnant at time of death 10 1 year before death y 9nan ®Natural Homic tle U M Na ❑Unknown Not p t but pregnant Unknown d pregnant within the past Accident ❑Pending Investigation within 42 days of death year Suicide Could not be determined DUE TO or as a consequence of):, 32. DATE. OF INJURY (Mo /Day/Yr) 31 TIME OF INJURY 34. PLACE OF INJURY. (Decedent's home, farm, street. construction Ole, W (Spell month) (248.1) nursIng home, restaurant. f est. etc) F 36. LOCATION OF INJURY: Le State City/ Town or County Zip Code W Street and Number or location:. Apartment Number 37. DESCRIBE HOW INJURY OCCURRED. IF TRANSPORTATION INJURY, STATE THE TYPES(S) OF VEHICLE(S) INVOLVED (Automobile, pickup, motorcycle. ATV bicycle. ele.) SPECIFY WHICH VEHICLE DECEDENT OCCUPIED, .i1 applicable 35. INJURY AT WORK? ❑Yes ❑No TRANSPORTATION 38a. WAS. DECEDENT Driver /Operator Passenger 38b. WHAT SAFETY DEVICES(S) DID DECEDENT USE/EMPLOY? INJURY ONLY Pedestrian Other (Specify) Seal belt Child safely seat ❑Helmet DA), bag None 0 Unknown 39a. CERTIFIER (Check only one, based on 015c,al capacity for This certificate) 0 PHYSICIAN PHYSICIAN ASSISTANT ADVANCED PRACTICE PROFESSIONAL NURSE To the best of my knowledge, death occurred at the lime, dale, and place, and due to the natural cause(s)/manner staled. CORONER On the basis of examination and /or investigation, in my opinion; death' occurred al the lime. dale, and place, and due ID the cause(s) and manner stated Signature end Title of Certifier t• JAY W. WILLEY II, 0.0. 39d. NAME, ADDRESS, AND ZIP CODE OF CERTIFIER (Type or print) JAY W. WILLEY II, 495 YELLOWSTONE POCATELLO, ID 83201 39b. LICENSE NUMBER 0 -00314 39C, DATE SIGNED 5 19 /2012 MM DD YYYY 40, REGISTRAR'S SIGNATURE 40b. DATE SIGNED. _5_/_2j_/ 201 MM DD YYYY TYPE OR PRINT IN PERMANENT BLACK INK DO NOT USE FELT TIP PEN FOR INSTRUCTORS SEE HANDa0065 CAUSE CF DEATH IF DEATH WAS DUE TO OTHER THAN NATURAL CAUSES, THE CORONER MUST COMPLETE AND SIGN 5165 THE CERTIFICATE PANCO (Rev)91 /10 IDAHO DEPARTMENT OF HEALTH AND WELFARE BUREAU OF VITAL RECORDS AND HEALTH STATISTICS State of Idaho �,7 Q CERTIFICATE OF DEATH 0 0 mfoovam;Fgaqz'gtfgant'AttZTelMrgrZ,Tn;'=""' Local Reg. No 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. O DATE ISSUED: 2 a 2 I A�rf Ay? This copy not valid unless pr pared on engraved border displaying state seal and signature of the Registrar, STATE OF IDAHO JAMES B AYDELOTTE STATE REGISTRAR :ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE ett 1 1YY T,•0/ t‘TLLTwk•Cilitl