HomeMy WebLinkAbout968742STATE OF WYOMING
SS.
COUNTY OF LINCOLN
FURTHER AFFIANT SAYETH NOT.
Witnessed my hand and official seal.
Commission Expires:
AFFIDAVIT
RECEIVED 12/28/2012 at 12:45 PM
RECEIVING 968742
BOOK: 801 PAGE: 505
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, Chester R. Sebastian being of lawful age and duly sworn according to law upon my oath
and depose and state:
1. That I am of adult age, a resident of Kemmerer, Wyoming, and the Affiant herein.
2. That by virtue of the conveyance which is recorded in the Office of the Clerk for Lincoln
County, Wyoming, located at Kemmerer, Wyoming in Book 502PR on page 459 is
recorded a Warranty Deed dated October 22, 2002, which conveys unto Joe Sebastian
Chester R. Sebastian and Hildegarde Sebastian, the following property more particularly
described, to -wit:
Lots, 5, 6, and 8 of Block 43 of the First Addition to the Town of Kemmerer,
Lincoln County, Wyoming
3. That said Joe Sebastian died on the 18th day of November 2012, and a copy of the
original certificate of death, certified to an a true and correct by public authority in which
the original of said certificate is a matter of record, is attached hereto as Exhibit "A
4. That by reason of death of said Joe Sebastian and by reason of state statutes, the
decedents interest and title in said property has terminated and title to the real property
conveyed thereby has vested absolutely in Chester R. Sebastian and Hildegarde
Sebastian continuously since the death of the said decedent.
Chester R. Sebastian
00
The fore g instrument was subscribed and sworn to before me by Chester R.
Sebastian this t1 day of December, 2012.
ry Public
April Br'nski Rotary Public
County of na
Lincoln t ;13
by Commission Expires 1 1S
CERTIFICATION OF VITAL RECORD'
PE OR
PRINT IN
PERMANENT
BLACK INK
DECEDENT
IF DEATH
OCCURRED IN
INSTITUTION
SEE HANDBOOK
REGARDING
OMPLETION OF
RESIDENCE
ITEMS
ISPOSITIOF
RADE CALL
CERTIFIER
REGISTRAR
CAUSE OF
DEATH
ONDITIONS.IF
ANY WHICH
GAVE RISE TO
IMMEDIATE
CAUSE
STATING THE
UNDERLYING
)CAUSEIL.AST
la. DECEASED -NAME (FIRSTM1DDLE,LAST,SUFFIX)
Joe
SEBASTIAN
3b. CITY, TOWN, OR LOCATION OF
/Sparks
DEATH
9a, STATE OF BIRTH (If not U.S A.,
name country) Wyoming
13 SOCIAL SECURITY. NUMBER
520 -14 -2925
15a. RESIDENCE STATE
Wyoming
3c. HOSPITAL OR OTHER INSTITUTION Neme(If not either, give street
and number)
The Pond House of Nevada, LLC
9b. CITIZEN OF WHAT COUNTRY
United States
14a. USUAL OCCUPATION (Give Kind of Work Done During Most
of Working Life, Even If Retired) Bartender
COUNTY
16. FATHER/PARENT NAME (First Middle Last Suffix)
Chester SEBASTIAN
6. Hispanic Specify
No Non Hispanic
7a. AGE -Last
birthday (Years)
89
15c. CITY, TOWN OR LOCATION
Kemmerer
2. DATE OF DEATH (Mo /Day/Year)
November 18, 2012
3a. COUNTY OF DEATH
Washoe
3e.If Hosp. or Inst. indicate DOA,OP /Emer. Rm.
Inpatient(Specify)
Inpatient
7b. UNDER 1 YEAR
MOS I: DAYS
8 DATE OF BIRTH (Mo /Day/Yr)
July 16, 1923
11. MARRIED, NEVER MARRIED, WIDOWED, 12. SURVIVING SPOUSE (if wife, give
DIVORCED:(Specify) Married maiden name) Hildegarde SPENCER
14b. KIND OF BUSINESS OR INDUSTRY
Bar
15d STREET AND NUMBER
814 Beech Avenue
15e. INSIDE CITY.
LIMITS (Specify. Yes
or No) Yes
17. MOTHER/PARENT NAME (First Middle Last Suffix),
Ida GRIFF
PARENTS
18a. INFORMANT -NAME (Type or ;Print)
Hi!degarde SEBASTIAN,
19a BURIAL, CREMATION, REMOVAL, OTHER (Specify)
Cremation
20a. FUNERAL DIRECTOR- SIGNATURE (Or Person Acting as Such)
CAROLL DAVID HIGGINS,
SIGNATURE AUTHENTICATED
TRADE CALL NAME AND ADDRESS
21a. To the best of my knowledge, death occurred at the time date and place and
due to the caUse(s) stated. Signature Title). SIGNATURE AUTHENTICATED
JEFFREY NEAL GINGOLD M.D.
21b, DATE SIGNED (Mo /Day/Yr) 21c. HOUR OF DEATH
November 20 2012 18'41
21d. NAME OF ATTENDING PHYSICIAN IF OTHER'THAN CERTIFIER
23a NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN, MED CAL EXAMINER,-OR CORONER) (Type or Print)
Jeffrey Neal Ging.oJ M.D. 3101 Plumes Reno, NV 89509
24a. REGISTRAR (Signature)'
BRIDGES SANDI
SIGNATURE AUTHENTICATED
25. IMMEDIATE CAUSE I (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c).)
PARTY (a) Prostate cpncer
DUE TO, OR AS A CONSEQUENCE OF:
DUE TO OR AS A CONSEQUENCE OF
DUE. TO, OR AS A CONSEQUENCE OF:.
t Interval between onset death
i iInterval between onset and death
Interval between onset and death
Interval between onset and death
PA OTHER SIGNIFICANT. CONDITIONS- Conditions contributing to death but not resulting in the underlying cause given in Part 1.
28a. ACC., SUICIDE, HOM., UNDET::.
OR- RENONN INvEsT: (Sbeedy)
28e. INJURY AT WORK (Specify
Yes or No)
28b. DATE OF INJURY (MO /Day/Yr)
19b. CEMETERY OR CREMATORY NAME
Truckee Meadows Crematory
20b. FUNERAL
DIRECTOR LICENSE
20
28f. PLACE OF INJURY- At home, farm, street, factory, office:
building, etc. (Specify)
20c. NAME AND ADDRESS OF FACILITY
Truckee Meadows Cremation and Burial
616 South W8115 Avenue Reno NV 89502
22a. On the basis of examination and /or inves igation, in my opinion death occurred at
LL the time date and place and due to the cause s) stated. (Signature Title)
E 0 22b. DATE SIGNED (Mo /Day/Yr)
N
00 "22d. PRONOUNCED DEAD (Mo /Day/Yr)
24b. DATE RECEIVED BY REGISTRAR
(Mo /Day/Yr) November 20, 2012
'.85. DESCRIBE: HOW INJURY OCCURRED
19c. LOCATION City orTown State
Sparks Nevada 89431
22c. HOUR OF DEATH
22e, PRONOUNCED DEAD AT (Hour)
24c. DEATH DUE TO COMMUNICABLE DISEASE
YES NO
27. WAS CASE REFERRED
TO CORONER (Specify Yes
or No) No
28g. LOCATION
CITY OR TOWN STATE-
WASHOE COUNTY HEALTH DISTRICT'
005 :r
CERTIFICATE OF DEATH 2012018320
STATE FILE NUMBER
VITAL STATISTICS- RENO, NEVADA
STATE REGISTRAR
This is a true and exact reproduction of the document officially registered and
placed on file in the office of the State Registrar and Vital Records.
11/28/2012
18b. MAILING ADDRESS (Street or R.F.D. No City or T wn State Zip)
814 Beech Avenue Kemmerer, Wyoming 83101
0001 01014 CERTIFIED COPY OF VITAL RECORDS
i s„_
DEPUTY REGISTRAR SIG ATURE AUTHENTICATED
This copy not valid unless prepared o[r engraved border displaying date seal and signature of Registrar.
ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE/AL
VRS- Rev- 20120523e