HomeMy WebLinkAbout968920I, Rosie Ann Kennedy, also known as Rose Kennedy, being first
duly sworn under oath do hereby declare as follows:
1. On or about the 20th day of November, 1990, my mother,
Katerina Celebrin, also known as Katie Celebrin, died as is
evidenced by the official certificate of death attached hereto and
incorporated herein by this reference.
2. At the time of her death, she owned an interest in real
property as a joint tenant with right of survivorship, said real
property being located in the County of Lincoln, State of Wyoming,
and is more particularly described as follows:
The Lot Numbered Three (3) of Block Numbered Fifty -four (54) in the Second Addition to the Town
of Kemmerer, Lincoln County and State of Wyoming, as surveyed, platted and recorded.
Together with all buildings and improvements thereon or thereunto in anywise appertaining thereto.
3. Said real property was originally conveyed to, Ferdinando
Celebrin and Katie Celebrin, husband and wife, Fred J. Celebrin,
Rena Kathleen Celebrin and Rosie Ann Kennedy, as joint tenants with
right of survivorship by Warranty Deed dated July 19, 1976, and
recorded on July 19, 1976, in the Office of the Lincoln County
Clerk and Ex- Officio Register of Deeds in Book 128PR, Page 544.
4. By reason of my mother's death, her title and interest in
the above mentioned real property has passed to the surviving joint
tenants identified in the above described Warranty Deed.
STATE OF WYOMING
ss
COUNTY OF LINCOLN
The above and regoing instrum nt was subscribed and sworn to
before me this el day of t-t 2013, by Rosie
Ann Kennedy also known as Rose Kennedy.
WITNESS my hand and official seal.
My commission Expires: IS
RECEIVED 1/7/2013 at 4:50 PM
RECEIVING 968920
BOOK: 802 PAGE: 307
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
t4 04444
Rosie Ann Kennedy also known as
Rose Kennedy
aa z� cL
No Public 4
April Brunskl N Notary Public
State Cf
wymina
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00307
LOCAL FILE RAWER 1028
TYlv +.OE4EDENr -NAPE Fr1ST
FE 1"M NENT Katerina
F(.
PoK a SOCIAL SECURITY IAAlER
INSTRUCTIOus
SEE
HANDBOOK
DECEDENT
INFORMANT
DISPOSITION
CERTIFIER
CAUSE
OF DEATH
20:MANIER OF DEATH
673126
0. NAM AND ADDRESS OF CERTF81(PHYSCIAN OR CORME(O (Typ. or Ma)
;Y am, Wdic urilmWN.
Cam. tram 11111111711.11110
CAUSE (a.a.a rRum DUES, (OR AS A CONSEQUENCE OH:
amt kWsl.d manta
rootaiS h OMR EAST
This is a true certification of the document on file in the office of Vital
t A r' Statistics Services, Cheyenne, Wyoming.
4 DATE ISSUED:
0 2012
DEC 27
l ill fl This copy is not valid unless prepared on paper with an engraved border.
DEPARTMENT OF HEALTH
STATE OF WYOMING
DIVISION OF HEALTH AND MEDICAL SERVICES
CERTIFICATE OF DEATH
PART. OTHER SKINFICAMr COADRtONSCMddwm cmPgaiy to ear hbut not Maud to mom BNS, al PART
LAST
Celebrin
7. RACE OF DEATH (OMR way ma
IIOSRTAL' I
J�Y
.1 aBwa eawp.usm Dos N.ai,B Florae R.+ase on. (saaIN)
7h FACLRr WANE (N•M Satisfies 9As west and scram) 7e CCVr10Ma OR LOCATION OF DEATH
South Lincoln Medical Center Kemmerer
L STATE OF BIRTH IN not h U S: A. now country) 1111 A MARRED,NEWRIJARTEIA Ia 9unotwoo smusa Nhi BI. mrlden now L
WDON®,awRDED apacfy)
Widowed
MATE .MESDAMES
a: WOOF SEAM (Ala. ay, Y,.)
Female November 20, 1990
wan 1 DAY.:. a DATEOF BIRTH (Ma Dy. Yr.)
7M COUNTY OFEEATH
Lincoln
Wyoming
1 1, WAS n* DECEDENT
ttnt Rita/ N ARMED i(s AFp1CLS7 13.: USUAL ODCORATICN (Gn,. 7e4 at over none R71 asst 123k OF RUSHER' OR ESNSFR?
(Si 1Wy P ar a: a twang E)4 also O d'w
rot) i
No Homemaker I Home
13a RESIDENCE• STATE 190. tb11NTY 1 711 CRY, TOWN OR LOCATION 13d. STREET AND NAMED
Wyoming Lincoln Diamondville 510 Opal
13. INSIDE WY (11413? 1 WAS DECEDENT OFR: PAW ORRNt /A.RACE.NSaeoh iMSA Ya OECEDEM' FOIM,AitON
(SP.dtY sm. no Los* a or yeall/M. aMdN Bari. WIaq. P.X.
on o Mantas PUSbRiven. I (SA.drl. 0..dAY.dy msa4.Eq.NCm,pLMd)
Yes I ERS+Atwy/S.awdsy (0.12)'Lb 'Callow 5.1
w® r.. C1 (506.4.) White 3
17. FATHERS NAME Rn Mama LW ID OMENS NAME FOW LWa. Malden Sums
n I R
Batista Carolla Maria Borino
IB.NFORNAM•NMIE (rypa a' 7 .0 l gta R E1A117 115FBP 10 DECE7ENr
Rose' Kennedy I Daughter
TBa MALNF ADDRESS STREET OR RFD g
NUEEFA CRT On TOWN STATE g ...DE
513 Lignite Kemmerer, Wyoming 83101
1111 Loa LOCATION UTiY CR.TOWN STATE
20LB,b11,.a,wtlm.RW0 20G GATE (Mq Day, Yr 31111C9ETBIY 011 CRBI
Aow BbM Otlio (E1wM+Y1
B rial 11/24/90 D oAd Cemetery
Diamondville, Wyo.
YtA AUIERkLS01VIc0 Uf.'EI d Parson.00-g Number 21). LE OF Nam NamBlc a0ORE9.T OF FACl1TY
N
R 440 raldall Funeral Home ..28 Kemmerer, Wyo.
22 Rat el my a'YEY.,11111, 21 br,46 M 23 On the bow A omWdon*War hYSBWNwl i1 PM W+ABm RMR PCwnle
NB 11Mey.l.ue.e r a.'/ w leere -me d m Be meald,l lea
MY sad rat �.j• ga (AAyMWe ,rM rRh)
271a DATE SIDIRD Day, Yr.) 2211 HOUR OF DEATH R 124 DATE SEINED (Ma Day, Yr 23UWE/ROF DEATH
%I /9 s:05 AN
F¢ L NAIVE 0) ATTENDING PHYSICIAN IF OTHER THAN CER0PER (lop. or Pratt) 8
22 23d PRONOUNCED DEAD
N. PRONOUNCED DEAN(/NW
Gary R. Noe 702 Onyx Dr. Kemmerer, Wyo. 83101
m. REGISTRAR. J xsaDATE RFDEIV®Br nvp. rag n.)
(svha,.r: «,I.„+r� j� Nov 23 ....1440
L Fine B. bream. R,... w eared Maas Do not was Ma mode al *Ma oath s cardiac 24 wnt{i.Nry anw,rm,a ham Lid only cm a,iNmaYA Loa iIn M Bal11vw1
WEIMAR CAUSE Nam s n 1 Onset /Ad Math
ds.re or madam 1 j f. Y'<s �•y
1111 I I rti i4.jr.'S
OUE ODOR AS A CON wrs OH: 1 1 C. �rJ I00 1
SsDFN11W W rr
yldte,W DUE 10 I0R ASACONSEO OFi: 1
1
27. AUTOPSY Moody 30. WAS CASE ADD TO CORONER
Mo rat) (spumy boar a •P)
No No
30d DESCRIBE HOW INJURY OCCURRED
3d. LOCATION (Sarkand amts.. or Rural FR AN Nwl.w. Coy or Tama Sam/
J ames McBride
Deputy State Registrar
Yi 1 Y 'r t(
`1t ..Frr `rdfif'/. a
CERTIFICATI ITAL RECORD
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