HomeMy WebLinkAbout969130STATE OF WYOMING
SS.
COUNTY OF LINCOLN
RECEIVED 1/23/2013 at 9:16 AM
RECEIVING 969130
BOOK: 803 PAGE: 183
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
I, GLORIA L. KNIGHT, being duly sworn under oath, state as follows:
00183
1. That Floyd J. Knight had tenancy by the entireties, as husband and wife, with me
in land in Lincoln County, Wyoming, more particularly described in the Warranty Deed that was
recorded in the Lincoln County, Wyoming land records in Book 330PR at Page 658 on June 21,
1993 as Instrument No. 766681. Attached hereto is a copy of that Warranty Deed.
2. That Floyd J. Knight died on February 1, 2007. Attached hereto is an original
copy of the Certificate of Death issued for Floyd J. Knight.
3. That pursuant to Wyoming Statutes 2 -9 -102, I certify that the tenancy by the
entireties of Floyd J. Knight has been terminated by his death and that title to the above
referenced land is now in the name of Gloria L. Knight, a single woman.
DATED this 11s+ day of January, 2013.
WITNESS my hand and official seal.
M KEVIN 3 ^i'LES NOTARY PUBLIC
County of State of
Linccin u �i:,` Wyoming
My Cor mi or r Juiy 16, 2015
My Commission expires:
ACKNOWLEDGED, SUBSCRIBED AND SWORN TO before me on this Zt day
of January, 2013 by GLORIA L. KNIGHT.
WARRANTY D
G58
JON CLARK. and DEANN4 L CIARk, husband and wife
grantor of..
CONVEY and WARRANT to
WITNESS; the hand of said grantor this
Signed in the presence of
STATE OF WYOMING.
County of L•ineeitiT i i
On the II +lL day of
A. D, 19q3 personal y appeared d before me
I I
Jon Clark Deanna L. Clack!
County of
I i
LLOYD J. NIGHT and pLoRIAiL. KNIGHT, husband and wife
as tenants by the entireties
DEn Ju ne 1993 "T 9A 11
IN BOOK
330P R'
NO, 7666,•.L'l. crr't3.R.! "'CretPAK
maniocs of Box 262, I ayne :WY 83127
for the sum of Ten dollars and other good and valuable consideration
the following described tract of land In Lincoln County, State of Wyoming,
hereby releasing and waiving all rights under and by:virtue of the homaatead exemption lama of tha
Stara, to -Hitt
A portion of the of Section 11, T35N, R119W, 6th P.M., Etna, Lincoln County,
Wyoming being more particularly described as follows:
BEGINNING at a point'in� the West line of said Section 11, said point being 1210.00
feet South from:the Nor hwest corner of said SW's thence running East 211.74 feet;
thence S0 56'40 "W, 123.25 feet; thence N89 47'22 r 'W, 209.71 feat to a point in first
said West line;; thence North along said West line, 122.46 feet to the Point of
Beginning. SUBJECT TO a portion of the Right -of -way for U.S. Highway 89 over the
West 56.00 feet of the property.
Subject to reservations and restrictions contained in the United States Patent and
to easements and rights -of -way of record or in use.
Together with all improvements and appurtenances' thereon.
Jon
Deanna
i 1
;the'jlgbet "9. of,itte Within Itisttu'ment! who duly
pciigovilealg9tl gifjte.tha the y; etio the same
as their ;deed. I 1
Vi' c
':v i u 1 '^p
A,Jui..,1 CC)4 J
.Coirimission'expirest q-ia-,6 M Itary Public
Residing In ,J fi S JJ f '1L/ 1
t
land 11111111nnery
day of j t-A —A- A. D. 19q-
Entry No.
4
RECORDING DATA
State of Wyoming. hereby
Fee
RECORDED INDEXED
PLATTED 0 ABSTRACTED❑
COMPARED DELIVERED .0
001.811
CERTIFICATION OF VITAL RECORD
s
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ila r VOS
CI O
A
.H44*1401
TYPE OR
PRINT IN
PERMANENT
BLACK INK
00 HOT USE
FELT TIP PEN
FOR
MSTRUCTIDN4
SEE
HANDBOOKS
DISPOSITION
PLACE OF
DEATH
DATE OF
DEATH
CAUSE OF
DEATH
ITEMS 32.38
TO BE USED
OR EXTERNA
CAUSES ONLY
(CORONER)
MEMEMMI
F DEATH WAS
DUE TO OTHER
THAN NATURAL
CAUSES,
THE CORONER
COMPLETE AND
SIGN THE
CERTIFICATE
:44HF9 tl d(,111
OATS FILED BY STATE REGISTRAR:
E
1, DECEDENT'S LEGAL NAME (Include AKA's it any) (First, Middle. Last, Suffix)
Floyd James Knight
4a. AGE -Last Birthday 4b. UNDER 1 YEAR 40, UNDER 1 DAY 5. DATE OF BIRTH (Mo/Day/Yr)
84 (Years) May 8
7a. RESIDENCE STATE OR FOREIGN COUNTRY 7b. COUNTY
Wyoming
7d. STREET AND NUMBER
107662 Highway 89
8, MARITAL STATUS AT TIME OF DEATH.
6I Married 0 Married, but separated 0 Widowed 0 Divorced 0 Never married 0 Unkno
10. EVER IN U.S.
ARMED
FORCES?
f4 Yes
0 No
113. FATHER'S NAME (First, Middle, Lost. Suffix)
William James Knight
12a. MOTHER'S MAIDEN NAME (First, Middle, Lasl, Suffix)
Minnie Roberts
1 3a. INFORMANTS NAME (Type or print)
Gloria Knight
14. METHOD OF DISPOSITION
0 Burial 0 Cremation
LT Donation 0 Entombment
IC Removal from Idaho
O Olher (500
173. S
Schwab Mortuary
44 East 4th Avenue
Afton, Wyoming 83110
9F FUNERAL S ICE LIC� ERSON ACTING AS SUCH ,t 17b. L CENSE NUMBER (Of licensee)
M 676 0 Yes xl No
PLACE OF DEATH (19.22)
k 19a. IF DEATH OCC RRED IN A 11050 AL: 1* 19b. IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
IQ Inpatient ,0 ER/Outpatient 00 DOA 140 Hospice facility sO Nursing horn /Long term care facility 60 Decedent's home r0 Other (Specify)
k 20. FACILITY NAME (II n9) (acilily, give *eel and number) 21. CITY, TOWN, OR LOCATION OF DEATH, AND ZIP CODE 22. COUNTY OF DEATH
Eastern Idaho Regional
Medical Center Idaho Falls 83404
23. DATE OF DEATH (Mo /Day/Yr) (Spell month)
February 1, 2007 February 1, 2007
27. CAUSE OF DEATH
PART I. Enter the chain of events diseases, Injuries, or complications Ihei directly caused the death. DO NOT enter terminal events such as card'ac
arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line:
B'Yes
0 No
0 Probably
0 Unknown
32. DATE OF INJURY (Mo/Day/Yr)
(Spell month)
36. LOCATION OF INJURY: Stale
Month, i Dan HOwl MN UIes
1 I
STATE OF IDAHO
IDAHO DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF HEALTH POLICY AND VITAL STATISTICS
Slate of Idaho
CERTIFICATE OF DEATH STATE FILE NO.
was Nr. BEUS .:CrFevwFxc r=3.4 i1%.7aaLral��nlAMOpea noc,, E Local Reg. No. Il
Lincoln
3b, RELATIONSHIP TO DECEDENT
wife
15. PLACE OF DISPOSITION (Name and address of cemetery.
crematory, other place
Etna Cemetery
Etna, Wyoming
124. TIME OF DEATH
1302 (24hr)
SC-Vr/1 9)770 //7L1C /C_
IMMEDIATE CAUSE (Final
disease or condition
resulting In death)
Sequentially est conditions,
II any, leading to the cause
listed On line a. Enter the
UNDERLYING CAUSE
LAST (disease or injury
that initialed the events
resulting in death)
PART 11. Enler other significant conditions cgnirlbu)In010 deal( but not resulting In the underlying cause given In Pan
/=E /,A-4A, J. ,C' fc. //r /yr(ur2l c:Vi'7ff f tt/en, C-6,,,04, A'7YC//t
/ti/444,{?70V ?'Z-- /J� /LL ?=-tom 4o4"
29. DID TOBACCO USE 30.10 FEMALE (Aged 10.54):
CONTRIBUTE TO DEATH?
Du4Salaoa.araawvmce o0l -,r/ 71,0)
b. Me 77M/il J/
OUE TO (or an a mneeeuence o0:
A)n,oi ;i /v1,.1't retoc-,
DUE TO (or as a ronsm0enoe o0:
0 Not pregnanl within past year
D Pregnant at time of death
0 Not pregnant, but pregnant
Within 42 days of death
33. TIME OF INJURY
(2401)
I have reviewed and if necessary amended the medical section
413. REGISTRAR'S SIGNATURE n /P
C .w YJ riauzl an•mi/A,r,r "%)o r
CTATIC:T V' AI IMIDr10MATImM
This is a true and correct reproduction of the document officially registered and placed
on file with the IDAHO BUREAU OF HEALTH POLICY AND VITAL STATISTICS.
DATE ISSUED: A4,11
This copy not valid, unless prepared on engraved border
displaying state seal and signature of the Registrar.
Etna
0 Nol pregnanl, but pregnant 43 days
to 1 year before death
0 Unknown if pregnant wilhin the past
year
7e. APT. NO.
34. PLACE OF INJURY (Decedent's home
nursing home, restaurant, forest, etc.)
2. SEX
Male
SOCIAL SECURITY NUMBER
6. BIRTHPLACE (City and Stale, Ternlory, or Foreign Counlry)
922 Amarillo, Texas
7c. CITY OR TOWN
7f. ZIP CODE
83118
9. SURVIVING SPOUSE'S NAME (H wile, give maiden name)
Gloria Livingston
11b. BIRTHPLACE (Sale, Territory, or Foreign Counlry)
Mississippi
12b. BIRTHPLACE (Stale, Territory. or Foreign Counlry)
Tennessee
13c. MAILING ADDRESS (Street and Number, Cily, Stale, Zip Code)
P.O. Box 5172
Etna, Wyoming 83118
16. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
25. DATE PRONOUNCED DEAD (Mo /Day/Yr) (Spell month)
arm, street, construction site,
JANE S. SMITH
STATE REGISTRAR
7q. INSIDE CITY
LIMITS?
0 Yes R) No
8. WAS CORONER CONTACTED?
Bonneville
6. TIME PRONOUNCED DEAD
1302 (24hr(
Appmxlmale Interval:
1 Onset to Death
28a. WAS AN AUTOPSY X 288. WERE. AUTOPSY FINDINGS
PERFORMEO? 1 AVAILABLE TO COMPLETE
I THE CAUSE OF DEATH?
0 Yes 4 o 1 0 Yes 0 No
31. MANNNER OF DEATH
CYNalural 0 Homidde
0 Accident 0 Pending investigation
0 Suicide 0 Could not be determined
1 35. INJURY AT WORK?
0 Yes 0 No
City/Town or County Zip Code
Street and Number or Location Apartment Number
37. DESCRIBE HOW INJURY OCCURRED. IF TRANSPORTATION INJURY, STATE THE TYPE(S) OF VEHICLE(S) INVOLVED (Automobile, pickup, motorcycle, ATV, bicycle, etc)
SPECIFY WHICH VEHICLE DECEDENT OCCUPIED, if applicable
TRANSPORTATION 1383. WAS DECEDENT: 0 Driver /Operator 0 Passenger i364, WHAT SAFETY DEVICE(S) DID DECEDENT USE/EMPLOY?
INJURY ONLY i 0' Pedestrian 0 Other Specily) I 0 Seal bell 0 Child safely seal 0 Heinle 0 AP beg 0 None 0 Unknown
39a. CERTIFIER (Check only one, based on official capacity for this cenificaIe) 39b. LICENSE NUMBER
A PHYSICIAN To the best of my knowledge, death occurred a( the lime, date, and place, and doe to the na (u ret cause(s)/manner Mated. 'G2
0 CORONER On the basis of examn lion and /or inveslig911at, in 'opi Ion, death occurred al the Time, dale, and place, and hue'. the
cause Sec, DATE SIGNED s) and manner slated,
r_7- cri 1 7 -t 1 1 7
Signature and Tele of Certlfer P 1 Z l .4 v-2 MM. ':OD. YYW
39d. NAME, ADDRESS, AND P COD yep CERTIFIER ype or pnnl)
Douglas N. Whatmd e, M.D.; 3200 Channing Way; Idaho Falls, Idaho 83404
40a, CORONER'S SUBSEQUENT SIGNATURE IF NECESSARY: The coronees signature In this item supersedes that of the physician, 40b. DATE SIGNED
004 Ine coroner becomes the certifier of record.
MM DD- YYYY
41b. DATE SIGNED
MM
0018
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