HomeMy WebLinkAbout970547PH 13790
Tax I.D. No.
When recorded mail to:
Patsy Wells
3975 West 2300 North
Corinne, Utah 84307
RECEIVED 4/19/2013 at 12:18 PM
RECEIVING 970547
BOOK: 809 PAGE: 628
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT
I, Patsy H. Wells, being first duly sworn on oath, depose and say:
That I am a citizen of the United States of America over the age of 21 years, and a
resident of County of State of Utah.
That I was well and personally acquainted with Myrl Wells, in that certain Warranty
Deed dated July 30, 1996, and recorded j k 1 ct et le in Book 386PR, at
Page 449, as Entry No. 824006, in the office of tile Recorder of Lincoln County, State of
Wyoming.
That I know of my own knowledge that Myrl Wells trustee, in the said deed and Myrl
Leon Wells mentioned in the attached certified copy of the Certificate of Death was one and the
same person.
This affidavit is intended to terminate the said Myri Wells as a trustee of the Myrl Wells
Family Trust u/a dated April 1, 1975, in the following described property:
LOT 30 OF STAR VALLEY RANCH PLAT 2, LINCOLN COUNTY, WYOMING AS DESCRIBED
ON THE OFFICIAL PLAT THEREOF.
Patsy H'
Subscribed and sworn to before me this the day of April, 2013.
Notary Public
Phillips- Hansen Land Title Company
Notary Public
BRUCE M. EVANS
Commission #610655
My Commission. Expires
June 24, 2015
State of Utah
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Date bf Death:
City of Death:
Age:
Place of Birth:
Armed Services:
Spouse's Name:
Industry/Business:
Residence:
Mother's Name:
Facility or Address:
DECEQENT INFORMATION
November 22, 2012
Ogden
85
Brigham City, Utah
Yes
Patsy Lou.Hammerland
Agriculture
Corinne, Utah
Maria Cutler
McKay -Dee Hospital Center
INFORMANT INFORMATION
Name: Patsy Lou Wells ;Relationship: Wife
Mailing Address: 3975 West 2300 North, Corinne, Utah 84307
DISPOSITION INFORMATION
Method of Disposition: Burial
Place of Disposition: Corinne Cemetery, Corinne, Utah
Date of Disposition: November 27, 2012
FUNERAL HOME INFORMATION
Funeral Home: Myers Mortuary Brigham City
Address: 205 South 100 East, Brigham City, Utah 84302
Funeral Director: Gregory R Myers
MEDICAL CERTIFICATION
Medical Professional: Robert C Moesinger MD, 4403 Harrison Blvd #1635, Ogden (Weber), Utah 84403
CAUSE OF DEATH
Pulmonary failure [Onset: 10 Days)
Due to (or as a consequence of): Aspiration pneumonia [Onset: 14 Days]
Due to (or as a consequence of): Cecal volvulus [Onset: 23 Days]
Other significant conditions: Surgery, dementia
Tobacco Use: Non -user
Medical Examiner Contacted: No Autopsy Performed: No Manner of Death: Natural
Date Registered: November 27, 2012
Date Issued: November 28, 2012
This is an exact reproduction of the document registered in the State Office of Vital Statistics.
Security features of this official document include: Intaglio Border, V R images in top cycloids,
ultra violet fibers and hologram image of the Utah State Seal, over the words "State of Utah This
document displays the date, seal and signature of the State Registrar and the County /District Health Officer.
Janice L. Houston, State Registrar
Office of Vital Statistics
CERTIFICATION OF VITAL RECORD
CERTIFICATE OF DEATH
State File Number: 2012014424
Myrl Loen Wells
0
Time of Death:
County of Death:
Date of Birth:
Sex:
Marital Status:
Usual Occupation:
Education:
Father's Name:
Facility Type:
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*06 3139938*
Sir
06:20
Weber
July 11, 1927
Male
Married
Farmer
9th Through 12th Grade
Joseph Floyd Wells
Hospital Inpatient
062
Lloyd Berentzen
Director/Health Officer
County/District Health Department
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