HomeMy WebLinkAbout871583I, SYLVIA P. PEAD, aka SYLVIA PUTNAM PEAD, being duly sworn under oath, state
as follows:
1. Frederick E. Pead and I are the record owners, as husband and wife, tenants by the
entirties, of property in Lincoln County, state of Wyoming, pursuant to a Warranty Deed that
was recorded in Book 234 PR at Page 105 on December 19, 1985, as Instrument No. 647982;
said property being more particularly described as follows:
BEGINNING at the Southeast Corner of the Southwest One Quarter of the
Northwest One Quarter (SW1 /4NW1 /4) of Section Ten (10), Township 31 North, Range
119 West, of the 6 P.M., Lincoln County, Wyoming; Thence N00 °00'55 "E, along the
East line of the Southwest One Quarter of the Northwest One Quarter of said Section 10,
a distance of 132.00 feet; thence S89 °40'24 "W, a distance of 367.04 feet; thence
S29 °39'04 "E, a distance of 151.40 feet; thence N89 °40'24 "E, along the South line of the
Southwest One Quarter of the Northwest One Quarter of said Section 10, a distance of
292.10 feet to the point of beginning.
INCLUDING and together with all singular the tenements, hereditaments,
appurtenances and improvements thereon and thereunto belonging, and any rights of
Grantors to minerals thereunder, but subject to taxes, assessments, covenants, conditions,
restrictions, reservations, rights -of -way, easements and other similar encumbrances of
sight and or record.
2. Frederick E. Pead died on March 5, 1997. An original copy of the Certificate of Death
for Frederick E. Pead is attached hereto and incorporated herein by reference.
3. As the surviving spouse, I am hereby requesting that title to the above property be, by
the recording of this affidavit, vested solely in my name: SYLVIA P. PEAD.
DATED this 18th day of January, 2001.
+3.) 6
PR PAGE G
871588
STATE OF WYOMING
COUNTY OF LINCOLN
AFFIDAVIT OF SURVIVORSHIP
SS.
LiNCOLN
of
ON THIS, the 18 day of January, 2001, before me the undersigned, a Notary Public, in
and for the State of Wyoming, personally appeared SYLVIA P. PEAD aka SYLVIA PUTNAM
PEAD, who, under oath, signed the above Affidavit of Survivorship, and acknowledged that the
statements contained therein are true and correct to the best of her knowledge, information, and
belief.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my official seal, the
day and year in this certificate first above written.
JEWEL fl SMITH H NOTARY PlfC3LI(' 4,
County of State of
Lincnin Wyoming
My Coii?fi iq inn Expires May 1C. 2004
My Commission expires: 5 -1 8 -0 Li
TYPE
OR PRINT
W
PERMANENT
BUCK
WK
FOR
INSTRUCTIONS
SEE
HANDBOOK
PANE
110 I r,lAI11
VR 2 -89
4/94 15M
LOCAL FILE NUMBER
1. DECEDENT•NAME FIRST
FREDRICK
4. SOCIAL SECURITY NUMBER
529 -52 -6740
7. PLACE OF DEATH (Check only on.)
0 Inp.tlent,lit ER/ Outpatient 00A
7b. FAOUTY NAME (E act i0SWutM, Wye WM and number)
STAR VALLEY HOSPITAL
S. STATE OF BIRTH (0 not M USA., nem. county)
WYOMING
11. N418 DECEDENT EVER IN U.B. ARMED FORCES?
(8pacEy wa J
13.. RESIDENCE STATE
WYOMING
13.151310E CITY LIMITS?
Moony As or not
NO
18a. INFORMANT-NAME Ripe or Mot)
SYLVIA PEAD
18c MAILING ADDRESS
BOX 77
17. FATHER'S NAME FUN
GEORGE
25. REGISTRAR
18bnebn)
28. MANNER OF DEATH
13b. COUNTY
LINCOLN
14, NR88 DECEDENT OF I.usfhwic ORIGIN?
It or P wrtb 1UC.n, Eta)
MIDOIF
EUGENE
STREET OR R.F.p. NUMBER
20b. DATE (Ma, Day, W.)
Yee (Bp.ony)
MARCH 8, 1997
30e. DATE OF INJURY
(Month, D. 11v)
BRICK MASON
AWdl Last
BUDD PEAD
22d. NAME OF ATTENDING PHYS IAN IF OTHER THAN CERTIFIER (7664 or Pile)
',,"V?j A LIENATION
301). TIME OF
WURY
..CERTIFICATIO■ OF VITAL RECORD
1
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STATE OF WYOMING
DEPARTMENT OF HEALTH
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
Bb. UNDER 1 YEAR
Nursing Home R.•lanc. 0 Other (Bpcuyy
20c. CEMETERY OR CREMATORY -NAME
FAIRVIEW CEMETERY
This is a true and exact reproduction of the document on file In the office of Vital
Recods Services, Cheyenne, Wyoming.
DA E ISSUED' MAR 1 1 1997
To CITY, TOWN OR LOCATION OF DEATH
AFTON
10. SURVIVING SPOUSE (If wre, 8A'e maklan n.m.)
SYLVIA PUTNAM
CRY OR TOWN STATE
FAIRVIEW WYOMING
230;, C D a y
3 .S
MM 1. Enter the 26 0.u, hfudee, dFaomTiFuIlom thet cawed Math. '04 nal enter the mode d dying. NW x pNMC
30. or meplrNOry &nest, shoe. or Mart failure. UM only one cause on eadr0nl.
IMMEDIATE CAUSE (Final
p er
Dee -615
drew Of Meth) t 'fL Pr a y lC.� VL(, e'�.
McWWq M tl �.�v T J
DUE n TC (072 to A r
tMpMnIMMy 141 candela). a DUE TO (OR A8 A CON8EOU F1:
N any. heading M Immee61.
muse. Enter UNDERLYING a
CAUSE (Dlxw or IIVurY DUE TO (OR AS A CONSEQUENCE OF):
that In4MMd 01.014 4WOng M death) LAST Q
PART I. OTHER SIGNIFICANT CONWTIONS•Condflone 0ontr0adNg M death but not related M muse Glum In PMT 1
300 INJURY AT WORK?
!Spongy Du or no)
188. RELATIONSHIP TO DECEDENT
WIFE
This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar.
STATE FILE NUMBER
3. DATE OF DEATH (Ma, Dry, HJ
MARCH 5, 1997
B. DATE OF BIRTH Ma, Day, Yr.)
MARCH 22, 1939
12b. KIND OF BUSINESS OR INDUSTRY
BUILDING
7d. COUNTY OF DEATH
LINCOLN
13d. STREET AND NUMBER
SPRING CRF.EK ROAD
EMm.mary /S.borld.,y 10 -121 Canoga f 1•4 or O
12
18. MOTHER'S NAME Firm Middle Mahan Surname
ERMA GRACE ERICKSON
ZIP CODE
83119
UI'.4 0'..I I IUtJ
CL
1,1111E I:
22. H•'RO OEM
8:18 A.
24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER)Rype or 1Yia)
0.D. PERKES MD. 110 HOSPITAL LANE AFTON WYOMING 83110
20d. LOCATION CRY OR TOWN STATE
FAIRVIEW WYOMING
E UDENBF DO, Person AMIng Number 216. NAME OF FACILITY Number 210. ADDRESS OF FACJUTY
SCHWAB MORTUARY '45 44 E. FOURTH AVE., AFTON
my Ms 7� rIo or 0& ny •n 1 mowed Um u'r.la) aWSd. j L,. ■1 IM'tMM ate and Place n and d Jo Ni
(Slosh...rd ❑N) `a..� I 180.4" And 77711 Ili' a1A/. /AIL 'J
22b. DATE SICKED (Moe, �1CYe>' Rib. DATE 8i D NE
e: oft Day. /YJ 230. HO OF H
206. DATE RECEIVED BY REGISTRAR (Mo., Day, W.)
r C -ry
27. AUTOPSY (8pedy
ND yee or m
2E. WAG CASE REFERRED TO CORONER
f2p.ory w n rpm S
30d. DESCRIBE HOW INJURY OCCURRED
301. LOCATION (Street and lumber or Rural Palo Number, City or Town, Stab)
Luclnda McCaffrey
Deputy State Registrar
li: isisisrisi:' i�i: i�i: isisi•: isiii :isisisrii:isisisisisisisis is i: isi :i:ia1i:i:i:i:i:ili:ri:i:i:i;
8:18 A.M
23e. PRONOUNCED DEAD (Hour)
or:/8
W ing mss...
1 Onset and Death.
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