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Home My WebLink About969245STATE OF WYOMING ss. COUNTY OF LINCOLN RECEIVED 1/31/2013 at 11:57 AM RECEIVING 969245 BOOK: 803 PAGE: 622 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY AFFIDAVIT OF SURVIVORSHIP JERRY D. FLOYD, being first duly sworn upon his oath, deposes and states as follows: 1. On the 24th day of June, 1995, my wife, MARGUERITE ELAINE FLOYD, a/k/a MARGUERITE E. FLOYD, died, as is evidenced by the official certificate of death attached hereto and incorporated herein by this reference. 2. On the 26th day of June, 2010, my son, DENNIS MAX FLOYD, died, as is evidenced by the official certificate of death attached hereto and incorporated herein by this reference. 3. At the time of my wife's death and my son's death, they jointly owned certain real property with the undersigned and the undersigned's daughter, Janet RaNae Little, said real property being located in the County of Lincoln, State of Wyoming, and more particularly described as follows: Lot Four (4) in Block Forty -nine (49) in the Second Addition to the Town of Kemmerer, in the County of Lincoln, State of Wyoming, as said Lot is surveyed, platted and recorded. 4. Said real property was originally conveyed to JERRY D. FLOYD and MARGUERITE E. FLOYD, husband and wife, JANET RANAE LITTLE, daughter, DENNIS MAX FLOYD, son, and to the survivors as tenants by the entireties, and not as tenants in common, by Warranty Deed dated October 24, 1983, and recorded in the Office of the Lincoln County Clerk and Ex- Officio Register of Deeds on October 24, 1983, in Book 206PR at Page 458. 5. At the time of my wife's death and my son's death, they also jointly owned certain 006V, additional real property with the undersigned and the undersigned's daughter, Janet RaNae Little, said real property being located in the County of Lincoln, State of Wyoming, and more particularly described as follows: E 68' of Lot 1, Block 53, and E 68' of Lot 2, Block 53 in the Second Addition to the Town of Kemmerer, as surveyed and platted and recorded. Also, a 1973 14 x70 Brighton House Trailer. 6. Said real property was originally conveyed to JERRY D. FLOYD and MARGUERITE E. FLOYD, husband and wife, JANET RANAE LITTLE, daughter, DENNIS MAX FLOYD, son, and to the survivors as tenants by the entireties, and not as tenants in common, by Warranty Deed dated October 24, 1983, and recorded in the Office of the Lincoln County Clerk and Ex- Officio Register of Deeds on October 24, 1983, in Book 206PR at Page 457. 7. By reason of my wife's death and my son's death, Jerry D. Floyd and Janet RaNae Little, as joint tenants with rights of survivorship, are entitled to ownership of the above mentioned real properties. DATED this 3 c11-- day of o.m„�,r 2013. SUBSCRIBED AND SWORN to and acknowledged before me this al w day of 2013, by JERRY D. FLOYD. 0nuuiu 0 J� p /1, WITNESS my hand A.f is :My Commission Expires July 02, 2015 0 My Commission Expires: /'/,,C OV 0 17\ a Wic 2 Notary Public vnruu 9a. In WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES f iil t?) �iiit j( 0 C, ;)r �nllkl111 �1 I)itIi I ANY ALTERATION OR ERASURE VOIDS THIS CE RTIFICATION P 1j !!I I n7 FA ;N F r9t jddlq, �asl) 18. MAIDEN NAM OF M0 F q (I ,t T I I II I IIII Il illt 11 I II s l,lll'.' Ij ��r�l�>; L i Emma Julia 'R'd a� 1 INS 0I� ~V�61E RFI �IONSHIR�N9,MAILING ADDRESS OF INFORMANT p ll 1 1 °ID Ioyd'. (Husband) 514 Garnet Street KemnieYrel1 ;1 III IIIIIIIIi IIII' I��T t fjl 111 i1M�IIlAKYlllrlblMl /'�'llI 1 1 1q� 'Ii 1 1 1 111 111 1'Ip1 IyYw I 1 1 I'I I (l f y d1 1 II IIT p it.i.p t' oOii 1 knoWiedge, death occurred at the time dale, and place, and due to 1h* cairge,d) O(td IIII 1� 1 ,J,I III jL II I A E'IXAMIN� I AW ENFORCFJ,iFNT OFFICE(, I ,i I 111111 Ipl II II IIIII i t l III tl 1 1 ,1 11 II 'I R I� Q515 of rpnation and/or investigation, in my opinion, death Occurred at.lhe dMe baYq Apia 1 x,1 1 1 „I 1 11 27b 1Q T �itAh DITIT LBOF CERTIFIER 2�CI LIp1 SE I II Ill I IIII� III III II I'l (.r N /r �4 q I I IIII !Ir' 1111111 11'1 1 r' J q M 7�II IVI:x r4' 41 'j II P�9 NAM A N� clDR ESS OF SON WHO CERTIFIE HE CAU O D ATH (ITEM 31) (Type /pant) 8i,,, I IIII 1 1 1 'I IQ1 W n th tI IA1taard 1034 North 500 West Provo U� Alf, ,I l' 29 I I R C�IS.i1 �1 VRE q II d vI '1j111 1111111 I l REUIS'r I �i ,1. IIIIIII 1 P 1 PIre II IIII I 'll till II� 'II i 111I ilnl �I I Ill i4 11h t II 11 l 1 j ll II q l i1 11 S1IIIRAR I) NTER THD DISEASES$ INJURIES. OR COMPLICATIONS THAT CAUSED THE DEATH. DO NOT ENTER THE MODE l 1 11 I II I I bnlV' RAT(lmimR9$r S}IOCk, OR HEART F LIST ONLY ONE CAUSE ON EACH LINE. 11 11 ll }l� lul 11 III I I I I 1'11 lI lulbllr; 1 I ll 1 1 1 4 bNnpp (Fih81 J •Sel 1 fh9 f�11' n�1 l a "OUE O 0 ASn CDNki.,=&'T/ k.LJNY(/ A'"-c 1 II I I IIIIi Ili III I�+ d6c'P ILENyMl��1' loft? I�I(JAI.{,Ib�DEdEbPlb FIPS,TI I '1., Al uerite rEori d11O,PTE;,9T, r Al o ;itr;1y{ ei 5';�C ttasr nhdarl Is I !I I I I II Mont MF cFi'', 11`3 63 vrs ,PLACE OF DEATH (Chec OTHER: HOS,PITAht1 r1 �p I 'I Ir 114 i 1 'Ignlll l ��loVl�all�nt l I IQ DDA IIBCI {�IMI LQdATION OF`DEATH It I?rA 1 I ,A D 1 1I PINTI,IyI;I 4, PL STATUS T INe■ee Married iIJ•.II� V.I 1'' Ali I 1 �'l u Dlvbroe r. uwlopweD County Assessor 9 ''!IF Ii i IDE I STREET AND NUMBER 13b. CITY. TOWN. OR COMMUNITY I i 5y i Kemmerer 0):16 79.11 r;; 1D I11T� 1yI lx bpo l l I 14. WAS DECEDENT OF HISPANIC ORIGIN? 0 No. 1,:' ii11Il I 1 1 1 {h yes, specify) I I II Es xp511!il1�e11 I 03101 Mexican ❑Cuban Puerto Rican Other (Specify) 1111 3d' MANNE I N Or' DEATH I I I' Natural I,;ol Il ❑�Suic) 0 I'k )0V61 Move ttga h STATE OF UTAH 'DEPARTM OF HE ERTIFICATE OF DEATH G 1 ;iI i STATE FILE'llitjlf�l DLE LAST 2. SE)( 3A� pAT4, pF!I :E g l 7' aine Floyd F ur Ir UNDER I YEAR IF UNDER Y� 00UR5 6 BIRTHP (C1rya S ere r Fr,∎ 11 l IW rj!h II Fe I 15avc Hn„rc 1 AA•n„lee 1 15a. DATE OF INJURY (Month, Day, Year) Nursing Home Residence Other 8d. COUNTY OF DEATH TII= dYN 9 1 T i' V 26 not cerlilied by medical examiner, was death sported to b1.6,? 0 des/ U;� If yes, enter the date and hour reported: M.E,Case No.. OUE O10 AS NSEO OU OFI }Z P10 AS CONSEOUENDE OF) tl erl 35e.LOCATION (Street or rural route number. city or town, county and stale) Diamondvllle: IWT bm JnJ� c�'Ij'lll?' 8b. NAME OF HOB'PMA jNUtil' INGH MEi d! gIv sheaf addresl# b) J60gr(�H), II'1 1 111 1 l'. 1111:ii.11:. 32. IN YOI W OPINION, TOBACCO. uSE, BY THEltl c D rrobabty conlribuled to the cause of dealfl. ID Was the underlying cause of death Did not contribute to the cause Ot'Uea10 Is unknown in relation to the cause, of death' .I, 35b. TIME OF INJURY 45c IN AT WO (26 Hour Crock) Il,,11 311; DESCRIBE HOW INJURY OCCURRED (enter sequence of evens Whloh resuged'iribnjdnl John E. Brockert DIRECTOR OF VITAL STATISTIC ofi'the certificate on file in this office. This certified GbfSy'i5"I$ ¢r, Utah Code Annotated, 1953 As Amended. 1 1 I I P! Decedent: State File Number: 2010- 001974 Name: Dennis Max Floyd Gender: Male Social Security Number Date of Birth: May 05, 1955 Age at the lime of Death: 55 years bate and Place of Death: Date of Death: June 26, 2010 County of Death: Lincoln City of Death: Kemmerer Location: 510 Onyx Street Additional Decedent information: Place of Birth: Casper, Wyoming Residence: Kemmerer, Wyoming Marital Status: Divorced Armed Forces: Yes Name of Father: Jerry D. Floyd Name of Mother: Marguerite E. Kinghorn Informant: Jerry D. Floyd Relationship: Father Disposition: Method of Disposition: *Place of Disposition: Funeral Home or Facility: Facility: Cause of Death The immediate cause is listed on the first line followed by any underlying causes. (a) Cerebral Vascular Accident Other Significant Conditions: Manner of Death: Certifier: Type: Name: Address: Date Filed: STATE OF WYOMING DEPARTMENT OF HEALTH 0,0'62 CERTIFICATE OF DEATH Removal from State UFD Cremation Center, South Jordan, UT. Family Chapel Evanston, Wyoming Hypertension, Alcohol Abuse Natural Death Physician George C. KrelI,,M.D. PO Box 390, Kemmerer, :.Wyoming, 831.01 July 07, 2010 This is a true certification of the document on file in the office of Vita Statistics Services, Cheyenne, Wyoming S DATE 'ISSUED: Thursday;:;July 08 2010 SS. g( This copy notyand onless on paper with an engraved border. Gladys K. Breeden Deputy. State Registrar y ij CERTIFICATI Or 1 \1h,2 L,' -FrSDi 5