HomeMy WebLinkAbout969435STATE OF ARIZONA
COUNTY OF MARICOPA
WITNESS my hand and official seal.
Ilk AM. AMR. ANL
RECEIVED 2/12/2013 at 9:59 AM
RECEIVING 969435
BOOK: 804 PAGE: 373
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
SS.
I, GUSSIE W. JAQUES, being duly sworn under oath, state as follows:
1. That Dale D. Jaques had joint tenancy, 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 122PR at Page 579 on December 30,
1975 as Instrument No. 473473. Attached hereto is a copy of that Warranty Deed.
2. That Dale D. Jaques died on September 13, 2012. Attached hereto is an original
copy of the Certificate of Death issued for Dale D. Jaques.
3. That pursuant to Wyoming Statutes 2 -9 -102, I certify that the joint tenancy of
Dale D. Jaques has been terminated by his death and that title to the above referenced land is
now in the name of Gussie W. Jaques, a single wpinan.
DATED this day of Jarivary, 20 3,
ROSEMARIE ACOSTA
Notary Public Arizona
Maricopa County
My Comm. Expires Oct 21, 2016
My Commission expires: 026'i/ �1
GUSSIE W. JAQUES
ACKNOWLEDGED, SUBSCRIBED AND SWORN TO before me on this day
2013 by GUSSIE W. JAQUES.
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THIS INDENTURE, made this lc day of .December ,19 75
by and between LEISURE VALLEY, INC., a Corporation organized and existing under
and by virtue of the laws of the State of NEVADA, duly authorized to do business in the.
State of WYOMING and having its principal place of business in the County of Lincoln,
State of Wyoming, the GRANTOR, and _SALE D JAOUES and GUSSIE W. JAQUES,
Husband and Wife as Joint Tenants
1012 East Cambridge Road, Kaysville. Ut. 84037
of the County of DAVIS
the GRANTEE,
WITNESSETH: That the GRANTOR, for and in consideration of TEN DOLLARS
($10.00) in hand paid, the receipt whereof is hereby acknowledged, does, by these pres-
ents, grant, bargain, sell, CONVEY AND WARRANT unto the said GRANTEE, all that
certain tract, lot, piece, and parcel of land situate in the County of Lincoln, State of
Wyoming, and described as follows, to -wit:
LOT NINETY -FIVE (95) in STAR VALLEY RANCH PLAT SEVEN (7)
as platted and recorded in the Official Records of Lincoln
County, Wyoming
RESERVING THEREFROM all rights, title, and interest in and to any and
all minerals and rights appertaining thereto.
Subject to all declarations of covenants, conditions and restrictions of record.
IN WITNESS WHEREOF, the Grantor has caused its corporate seal to be here-
unto afli 4 and these presents to be signed by its duly authorized officer, the day and
year first above written.
(j'
T,, o
STATE OF Nevaria
COUNTY OF Clark
SS.
By
The foregoing instrument was acknowledged before me by
and Alden L. Stewart
this 15 day of December
Witness my hand and official seal.
My Commission expires: 1,1 -1 -7
State of UTAH
LEISURE VALLEY, INC.
A Nevada Corporation
,19 75.
F
RECORDED Dec 30, 1975 AT ..9.:.0.0 M.
12 ZPR KE
N BOOK 4--
NO. 4 6 8 n MMERER, WYO.
4�� ALAN E. ZIEGLER, CLERK
PHOI e C0E WED
Paul Judd
le'Of (jffider
County F Y
_s Nev. 1, 1976jI
CERTIFICATION OF VITAL RECORD"
Decedent: State File Number: 2012-002892
Name: Dale Delbert Jaques
Gender: Male Social Security Number:
Date of Birth: December 09, 1920 Age at the Time of Death: 91 years
Date and Place of Death:
Date of Death: September 13, 2012 County of Death: Lincoln
City of Death: Thayne
Location: 190 Dana St.
Additional Decedent Information:
(Place of Birth: Clearfield, Utah
Residence: Star Valley Ranch, Wyoming
Marital Status: Married Gussie W Wallace
Armed Forces: Yes
Name of Father: Thomas Delbert Jaques
Name of Mother: Jessie Myrtle Sim
Informant: Cindy Joy Jaques Relationship: Daughter
Disposition:
Method of Dirosition: Burial
Place of Disposition: Thayne Cemetery, Thayne, Wyoming
Funeral Home or Facility:
Facility: Schwab Mortuary, Afton, Wyoming
Cause of Death:
The immediate cause is listed on the first line followed by any underlying causes. Interval:
(a) Congestive heart failure years
(b) Atrial fibrillation
years e
(c) Pleural effusions months
s
(d) chronic pain months.
Other Significant
Conditions:
Manner of Death: Natural Death Time of Death: 18:00 (Actual)
Cartifier:
Type:
Name:
Address:
Date Filed:
Physician
Christian M. Morgan, M.D.
110 Hospital Lane, PO Box 579, Afton, Wyoming, 83110
September 26, 2012
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming.
(51 DATE ISSUEDINednesday, November 07, 2012
This copy is not valid unless prepared on paper with an etigmved border.
DEPARTMENT OF HEAL
d ames Jride
McB a„„„,...„
Deputy State Registrar