HomeMy WebLinkAbout968825STATE OF WYOMING
ss.
COUNTY OF LINCOLN
AFFIDAVIT OF SURVIVORSHIP
follows:
1. That Jane Marie Jenson, the decedent mentioned in the attached certified copy of the
certificate of death, is the same person as Jane M. Jenson named as one of the parties in that
certain Warranty Deed dated August 22, 2003, executed by Gary Eiden, Jr., a/k/a Garry
Eiden, Jr. and Trena Eiden, husband and wife to Harold B. Jenson and Jane M. Jenson,
husband and wife as tenants by the entireties, recorded as Item No. 892849 on August, 27,
2003, in Book 532PR at Page 481, 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:
I, HAROLD B. JENSON, being of legal age and first duly sworn, deposes and says as
Lot 58 of the Eiden Addition to the Town of LaBarge, Lincoln County,
Wyoming as described on the official plat of the Schmid Addition and Eiden
Addition to the Town of LaBarge, Lincoln County, Wyoming.
00861.
SUBJECT, however, to all reservations, restrictions, protective covenants,
exceptions, easements and rights -of -way of record, in sight, or in use.
58 Piper Way, LaBarge, Wyoming.
2. That Jane M. Jenson also had an interest with me in the personal property located on that real
property that is described as follows:
a. 1988 14 x 60 Champion Mobile Home
3. That I am the same Harold B. Jenson mentioned in the above referenced Warranty Deed 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 Jane M. Jenson, her previous estate in the property was terminated.
4. That the certified copy of the certificate of death indicates that Jane M. Jenson died on
August 4, 2012 in LaBarge, Lincoln County, Wyoming.
Dated this 3 day of December, 2012.
RECEIVED 1/3/2013 at 11:17 AM
RECEIVING 968825
BOOK: 801 PAGE: 861
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
HAROLD B. JENSON
STATE OF WYOMING
ss.
COUNTY OF LINCOLN
DENA A. HANSEN NOTARY Mr1
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NOTARY PUBLIC
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This Affidavit of Survivorship was subscribed and sworn to before me by Harold B. Jenson,
this 3! day of December, 2012.
Decedent: State File Number:
Name: Jane Marie Jenson
Gender: Female Social Security Number:
Date of Birth: February 23, 1955 Age at the Time of Death:
Date and Place of Death:
Date of Death: August 04, 2012 County of Death: Lincoln
City of Death: La Barge
Location: 58 Piper Street
Additional Decedent Information
Place of Birth: Salt Lake City, Utah
Residence: Kanab, Utah
Marital Status: Married Harold Bingham Jenson
Armed Forces: No
Name of Father: Asael Larson
Name of Mother: Odessa Unknown
Informant: Harold Bingham Jenson Relationship: Husband
Q isposition:
Mthod of Disposition: Cremation
Ice of Disposition: UFD Cremation Center, South Jordan, Utah
Alb
Funeral Home or Facility:
Facility: Ball Family Chapel, Evanston, Wyoming
Cause of Death:
The immediate cause is listed on the first line followed by any underlying causes.
(a) Acute Lethal Arrhythmia
(b)Hyperkalemia
(c) Overdose of Zantac
Other Significant Cirrhosis of the Liver
Conditions:
Manner of Death: Accident Time of Death: Approximate 13:18 ±1 hr
Injury Information:
Date: Of Injury: August 04, 2012 (Actual) Time Of Injury: Approximate 13!00 ±8hrs
Injury At Work? No
Location: 58 Piper St., LaBarge, Wyoming
Description: Overdose on Zantac
Certifier:
Type: Coroner
Name: Cliff Boyd; Deputy
Address: 274 N St, Box 57, Grover, Wyoming, 83122
Date Filed: September 26, 2012
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming,
IRATE ISSIJED:Thursday, September 27, 2012
This copy is not validlunless prepared on paper with an engraved border.
DEPARTMENT OF HEALTH
CERTIFICATE OF. DEATH
57 years
d arotitS
James McBride
Deputy State Registrar
2012- 002883
Interval:
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CERTIFICATION OF VITAL RECORD
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