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Hickman
loditleco
SINCE 1904
AFFIDAVIT
RECEIVED 5/14/2013 at 2:11 PM
RECEIVING 970978
BOOK: 811 PAGE: 463
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, WALTER R. EDDY, 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 UTAH
That I was well and personally acquainted with SHELLEY JEAN EDDY in that certain
Warranty Deed dated APRIL 16, 2013 and recorded in Book 809 at Page 510 as Filing No
970518. in the office of the Recorder of LINCOLN County, WYOMING.
That I know of my own knowledge that SHELLEY JEAN EDDY in the said deed and
mentioned in the attached Certified Copy of Certificate of Death as SHELLEY JEAN PARKER
EDDY was one and the same person.
This affidavit is intended to terminate the JOINT TENANCY of SHELLEY JEAN
EDDY in the following described property:
LEGAL DESCRIPTION
LOT 10, STAR VALLEY RANCH PLAT 4, Lincoln County, Wyoming, as described on the
official plat recorded June 1.9, 1985, as Instrument No. 637320
Tax Roll No. 12- 3419- 01 -2 -02- 128.00
Dated this -1 "k day of May 2013 A.D.
L i, firti
WALTER R. EDDY
,604tH
VM
63740
Commission expires:
Residing in: 1 \A\ c' \c 1V \�0'
TAMERA L. POE
Notary Public. Stale of Utah
Commission if 603955
COMM. EXP. 01 -054015
Rl,
INDIVIDUAL ACKNOWLEDGMENT
STATE OF UTAH
SS
County of NN c,
On the Cy day of May A.D. 2013 personally appeared before me
the signer() of the within instrument, who duly acknowledged to me that' 1 /site /they executed
the same.
Notary Public
1
00464
DECEDENT INFORMATION
Date of Death: April 24, 2013
City of Death: Layton
Age: 62
Place of Birth: Ogden, Utah
Armed Services: No
Spouse's Name: Walter R Eddy Jr
Industry, /Business: IRS
Residence: Layton, Utah
Mother's Name: Irene Chamberlin
Facility or Address 2839 E. 3700 N.
FUNERAL HOME INFORi NATI
Funeral Home: Lindquis Mo ytop
Address: 1867 Itkio h Fainiei Road to
Funeral Director: 1, 4 Barry L `Kelly k4
Date Registered: April 30, 201,
Date Issued: April 30, 2013
o
d,ERTIFICATE OF DEATH
State File Number: 2013005532
Shelley Jean Parker Eddy
Time of Death:
County of Death:
Date, of Birth:
Sex
MaritaLStatus
Usual Occupation:
Education:
Father's Name:
Facility Type:
INFORMANT INFORMATION
Naritie: Walter R Eddy,Jr Relationship:
Mailing Address: 2839 E. N., .ayton, Utah 84040
DISPOSITION INFORMATIO
Method of Disposition: Bum!
Place of Disposition: Lindquist's Memorial Gardens of „the Wasatch, Ogden, Utah
Date of Disposition: ilkpril .27 2013
An, ;Utah"84q41
16:35
Davis
March 17,1951
Female
Married
Revenue Agent
Bachelor's Degree
Robert V Parker
Home
Husband
MEDICAL CERTIFICATION
Medical Professionals Steven J Potter MD, Family i edicine,`307s,North 300 Wes t„Suite 3
84037
CAUSE OF DEATH
Cardiac Arrest
Due to (or as a- consequence of):,,
Due to (or as a consequence of): Ovarian Cancer [Onset: 6 Months
Tobacco Use: Unknoif, User
Y
Medical Examiner Conta 'Led. No Autopsy Performed: No Manner of Death, Nat urafi
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Kaysville, Utah
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CERTIFICATION OF VITAL RECORD
Janice-L. Houston, State Registrar 0 6 3 5 5 0 5 8 2*
-..I Office of Vital Statistics
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This is art exact reproduction of the document regtstered in the State Office of Vitat StatlSt+cs.
Security features of this official document include: Intaglio Border, V R images In top cyclpids,
ultra violet fibers and hologram image of the Utah State Seal, over the words "State ofiitah This
document isplays the date, seal and signature of the State Registrar and the County/District health' Officer.
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County/District Health= Departmni
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