HomeMy WebLinkAbout969572AFFIDAVIT ESTABLISHING SURVIVORSHIP
OF SURVIVING SPOUSE OF ESTATE BY ENTIRETIES
STATE OF c
ss.
COUNTY OF 1`NJ,C \Cop.-
June M. Lindquist, being first duly sworn, deposes and says:
1. That this affidavit is given, in accordance with Wyo. Stat. §2 -9 -102
(1977 as amended), to establish the survivorship rights of a surviving spouse and
to establish prima facie evidence that all facts recited her in arc true for the
purpose of such legal effect as may result therefrom by operation of law, pursuant
to Wyo. Stat. §2 -9 -103 (1977 as amended).
2. The affiant was the wife of Carl H. Lindquist at the time of his death
on September 25, 2011.
3. That the affiant and Carl H. Lindquist were the Grantees of an estate
by entireties as husband and wife with right of survivorship in one (1) warranty
deed executed by Carl H. Lindquist as Trustee of the Carl H. Lindquist Living
Trust dated October 3, 1985, conveying to the affiant and Carl H. Lindquist the
following described property:
Lot 52, Star Valley Ranch, Plot 2, according to that plat of record in
the Office of the County Clerk, Lincoln County, Wyoming.
4. That the above described deed was filed for record in the Office of
the Lincoln County Clerk, Lincoln County, Wyoming, on November 1, 2006, in
Book 638 of Photo, page 819, as Instrument No. 923968.
5. That the affiant and Carl H. Lindquist were the co- owners of a 1974
Granada Mobilehome whose Arizona Certificate of Title Number is
675M004008022, Issue Date 01/08/2004 as Film Number E008675M10.
6. That Carl H. Lindquist died on the 25th day of September, 2011, and
his death was duly registered as evidenced by the certified copy of the death
certificate attached hereto.
7. By reason of the foregoing, affiant, as survivor of an estate by the
entireties, is the successor in interest and sole owner of all right, title and interest in
and to the foregoing described real and personal property.
JAMES R. WILLS
Notary Public Arizona
Expires X15 08/15/2013
My Commission Expires
Ju M. Lindquist
ary Public
og=11
Subscribed and sworn to before me by June M. Lindquist this
day of 2013.
0003
RECEIVED 2/20 /2013 at 9:34 AM
RECEIVING 969572
BOOK: 805 PAGE: 84
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Date Issued: 11 -.17 -2011
STATE OF ARIZONA
STATE OF ARIZONA
DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS
CERTIFICATE OF DEATH State Fite NO.102 039819
This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS,
ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA.
Revised 04/2010
ADAMS
ASSISTANT STATE REGISTRAR
This copy not valid unless prepared on a form displaying the State Seal and impressed with the raised seal of the issuing agency.
6
PATRICIA
ANY ALTERATION OR ERASURE VOIDS THIS DOCUME 1
z.OF V
6.50 i)ai'hi1elut O1
Neagh CIA /i es
;;,/r VITA
CERTIFICATION OF. L RECORD
1 AEGEDENT'S LEGAL NAME FIRST, MIDDLE, LAST) 2 AKA'S (IF ANY) 3 DATE OF DEATH
SEPTEMBER:25
CARL HUGO LINDQUIST 2011
4. SEX 5, SOCIAL SECURITY'NUMSER" 6 DATE OF BIRTH 7. AGE UNDER YEAR UNDER 1 DAY
MALE 06 -18 -1916 95 I
8. MONTHS 9. DAYS i0 TE
HOURS 11 MINUS
12, PLACE OF DEATH HOSPITAL, 1 3 PLACE OF DEATH OTHER THAN HOSPITAL:
0 INPATIENT E.RJOUTPATIENT DEAD ON ARRIVAL NURSING HO OE OR LONG TERM SURPRISE GROUP HOME
CARE FACILITY
RESIDENCE III HOSPICE FACILITY M OTHER
14. FACILITY NAME 108 STREET ADDRESS IF NOT A FACILITY)' 15 CITY. TOWN 8 ZIP CODE OR LOCATION OFF DEATH. 16 COUNTY OF DEATH'.
SUNRISE GROUP HOME SURPRISE 85374 MARICOPA
17.. BIRTHPLACE (CITY AND STATE 08 FOREIGN COUNTRY( 16 MARITAL STATUS AT TIME OF 15. NAME OF SURVIVING SPOUSE (MAIDEN' f9 AMF IF WIFE}
DEATH
DULUTH, MINNESOTA MARRIED JUNE SWANSON
2t1 USUAL RESIDENCE STREET ADDRESS: 21. CITY AND COUNTY. 22, STATE 23. ZIP CODE'S 24 EVERE;Itv(,iTHE A'RI$EI'} ,i
FORCES
2501 W WICKENBURG WAY, 57 WICKENBURG, MARICOPA ARIZONA 85390 YES
25. WAS DECEDENT OF HISPANIC ORIGIN? 26 DECEDENT'S RACE(S). 27 Ir M,wRceN INDIAN R ALASKA NATIVE: "14, NOT .:f n.ls`?. HISPANIC
i .v
.T!i.0 PIclY PiO41#96>
,EF ASIAN itl ';',V) r8IMA8Y OR FA!a6t.tEU TWIS
D. YES, MEXICAN, MEXICAN AMERICAN, CHICANO BLACK, AFRICAN AMERICAN
D NATIVE HAWAIIAN
D YES, PUERTO RICAN I ASIAN INDIAN
O YES, CUBAN O CHINESE
ā¯‘FILIPINO
O OTHER PACIFIC ISLANDER (SPECIFY) ADDITIONAL TRIBE
0 YES, OTHER (SPECIFY') M ESE D OTHER (SPECIFY)
D GUAMANIAN OR CHAMORRO ADDITIONAL TRIBE:
0 UNKNOWN D KOREAN
66 000IJPATION D VIETNAMESE Q UNKNOWN
SAMOAN ADDITIONAL TAME QWNER D AMERICAN INDIAN 08 ALASKA NATIVE
29 FATHER'S NAME (FIRST, MIDDLE, LASTS 30 MOTHER'S NAME (FIRST, MIDDLE, A LAST NAME 08108 TO FIRST MARRIAGE?
HUGO LINDQUIST INGEBORG CARLSON
31, INFORMANT'S NAME 52: RELATIONSHIP 33 INFORMANT'S
JUNE LINDQUIST SPOUSE 2501 W WICKENBURG WAY 57, WICKENBURG, ARIZONA 85390
34 NAME AND ADDRESS OF FUNERAL FACILITY: 35.. FUNERAL DIRECTOR: 36 LICENSE
DAVID'S DESERT CHAPEL FUNERAL HOME 325 WEST YAVAPAI NUMBER
WICKENBURG, AZ DAVID M POYNER FUNERAL DIRECTOR F0891
37 METHODIS) OF 0180051TION: 38. NAME AND LOCATION OF 10 DISPOSITION FACILITY: 39 NAME AND. LOCATION OF 2r14 DISPOSITION FACILITY:
CREMATION REGENCY MORTUARY SERVICES. INC., SUN CITY, ARIZONA NONE
MEDICAL CERTIFICATION SECTION CAUSE OF,DEATI{PART i
IMdEDI CAUSE 40. A 41 APPROXIMATE INTERVAL
END STAGE ALZHEIMERS DISEASE UNKNOWN
DUE TOORASA 42.8
CONSEQUENCE 0F, 43. APPROXIMATE INTERVAL.
DUE TO OR AS A 44. C 45 APPROXI INTERVAL
CONSEQUENCE OF.
DUE TO OR AS A 46. D 47, APPROXIMATE INTERVAL:
CONSEQUENCE OF:
CAUSE OF DEATH P RT II
/El, OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING 49. INJURY' 50. INJURY AT WORK 51, MANNER OF DEATH 52 TIr EIOF DEATH
IN:THE UNDERLYING CAUSES GIVEN ABOVE:
NO NO NATURAL DEATH 6:20 PM 53 WAS AN AUTOPSY PERFORMED/ 54. WERE 867008V AVA.ILQqBL'c?0
NO COMPLETE THE CAUSE 00 088111
CAUSE AND MANNER OF DEATH CERTIFICATION
0 CertiFyinp Physician/Nurse PractitjonedPhyecssu,'s Asslctant- To the best of my 55. NAME OF PERSON COMPLETING CAUSE OF DEATH: 56 DATE CERTIFIED.
knowledge, death occurred due 101510 -Ouse(s) and manner doled.
D Medical Examiner/Tribal Law Enforcement Authority On the bests of examination,
and,ar rnveehgetton, In rrry Opusion, death occurred at the rime, dote, and piece, and
duie to the cnuse(e) and manner stated. ROSELAVENDER A. RICHARDS, M.D. 09-28-2011
57. CERTIFIERS ADDRESS: 58. NAME OF REGISTRAR- 59. DATE REGISTERED
2255 N 44TH ST STE 200 PHOENIX, AZ 85008 -7232 MICHELE CASTANEDA, MARTINEZ 11- 02-2011