HomeMy WebLinkAbout968839State of WY
ss.
County of Lincoln
Jeffrey A. Kallstrom, being first duly sworn upon His /Her oath, deposes and states as
follows:
1.On February 25, 2011, my wife, Denise Kallstrom passed away, as is
evidenced by the official certificate of death attached hereto and incorporated herein by
this reference.
2. At the time of death my wife jointly owned certain real property with me, said
real property being located in the County of Lincoln, State of Wyoming, and more
particularly described as follows:
ALL OF LOTS 18, 19 AND 20 OF THE TAYLOR SECOND SUBDIVISION, LOCATED IN
LINCOLN COUNTY, WYOMING, FILED SEPTEMBER 6, 1978 AS INSTRUMENT NO.
513535 IN THE OFFICE OF THE LINCOLN COUNTY CLERK.
3. Said real property was originally conveyed to Jeffrey A. Kallstrom and
Denise L. Kallstrom, h sband and wife as tenants by the entireties, by
1,.,tL( CC c\ tro_ dated /,2 and recorded in the
office of the Lih pin County Clerk and Ex- Officio Register of Deeds on 431. e
7 in Book at Page -I'-/ D .c_ Uf ,A
4. By reason of Denise Kallstrom death, I am entitled to sole ownership of the above
mentioned real property.
Dated this 27th day of December 2012.
Subscribed and Sworn to and acknowledged before me this 27th Day of December,
2012, by Jeffrey A. Kallstrom
Witness my hand and official seal.
RECEIVED 1/3/2013 at 4:02 PM
RECEIVING 968839
BOOK: 802 PAGE: 61
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Affidavit of Survivorship
Jay A Kallstrom
tary Public �o
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LORI THORNOCK
NOTARY PUBLIC
f STATE OF IDAHO
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Certifier:
Type:
Name:
Address:
Date Filed:
Decedent:
Name:
Gender:
Date of Birth:
Date and Place of Death
`Date of Death:
City of Death:
Location:
Additional Decedent Information:
Place of Birth:
Residence:
Marital Status:
Armed Forces:
Name of Father:
Name of Mother:
Informant:
Disposition:
Method of Disposition:
Place of Disposition:
Funeral Home orFacility:
Facility:
Cause of Death:
The immediate cause is listed on the first line followed by any underlying causes.
(a) Anoxic Encephalopathy
(b) Myocardial Infarction
(c) Atherosclerotic Cardiovascular Disease
Other Significant
Conditions:
Manner of Death:
Denise Kallstrom
Female
December 24, 1961
February 25, 2011
Casper
Wyoming Medical Center 1233 East 2nd Street
Montpelier, Idaho
Cokeville, Wyoming
Married Jeff Kallstrom
No
Dennis L. Jensen
Colleen Kay Long
Jeff Kallstrom
Removal from State
Montpelier Cemetery, Montpelier, Idaho
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
State File Number:
Bustards Funeral Home, Casper, Wyoming
Poorly Controlled Type I Diabetes Mellitus
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming..
DATE ISSUED: Wednesday, March 23, 2011
This copy, is not valid unless. prepared on paper with an engraved border:
Social Security Number:
Age at the Time of Death:
County of Death:
Relationship:
Natural Death Time of-Death'
Physician
Mark McGinley, MD
1233 East 2nd Street, Casper, Wyoming, 82601
N(vlarch 22, 2011
08:02 (Actual)
Gladys K. Breeden
Deputy State Registrar
49 years
Natrona
Husband
CERTIFICATI 1 VITAL RECORD
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