HomeMy WebLinkAbout9714192
UU473
u W>
cum
a c
a AFFIDAVIT
rna�
c E
o STATE OF KITSAP
SS.
COUNTY OF WASHINGTON
E
U
O 0
'0 0 1, Marion K. Mosher being of lawful age and duly sworn according to law upon my oath and
cn WY
depose and state:
1. That I am of adult age, a resident of Silverdale, Washington, and the Affiant herein.
2. That by virtue of the conveyance which is recorded in the Office of the Clerk for Lincoln County,
Wyoming, located at Kemmerer, Wyoming in Book 804PR on page 725 is recorded a Warranty
Deed dated September 2, 2011, which conveys unto Donald C, Mosher and Marion K. Mosher,
husband and wife, the following property more particularly described, to -wit:
W1/2W' /2NW1/4 Section 27, T23N R116W of the 6 Lincoln County, Wyoming
3. That said Donald C. Mosher died on the 22nd day of June 2009, and a copy of the original
certificate of death, certified to an a true and correct by public authority in which the original of
said certificate is a matter of record, is attached hereto as Exhibit "A
4. That by reason of death of said Donald C. Mosher and by reason of state statutes, the decedents
interest and title in said property has terminated and title to the real property conveyed thereby
has vested absolutely in Marion. K. Mosher continuously since the death of the said decedent.
FURTHER AFFIANT SAYETH NOT.
The foregoing instrument was subscribed and
k- day of 2013.
W ifiAsSiN'{ E1§nti4 a\S6 via seal.
NOTARY PUBLIC
STATE OF WASHINGTON
COMMISSION EXPIRES
MARCH 9. 2016
RECEIVED 6/11/2013 at 4:10 PM
RECEIVING 971419
BOOK: 813 PAGE: 473
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Marion K. Mosher
sworn to before me by Marion K. Mosher this
QA()
Notary Public
F*Nurrillar,
..f...Z,
..4(
U• Obly 7
■Tio
.1: 4.4 Alt:
T.V., Of TtaN
1PPeRfT RE T O'KHEA LT H
W4shin*.ckn SfateCerkifidate"pf)3eStp State'Pliq ber
,14, 1tWoT-A.'
1
'I Il.egal Narrie (IMIude AKA's iNany) Ficsi'. 1 f■iiiitclle L AST ';i Suffix
DONALD CHARLES,
2."Deajh Dat4
0221,2009
o
IT
:7:
3:.Sex,-(M/F),
Male
.Agec.Lasl Birthday
58
4b. Under 1.Yaar
Months Days
c,1::thaer 1Day
Hours :Minutes
Social'Securityumber re. Death''''-
Kits])
Sirfhdate
6/19/1-95.t
8a: Birthplace (City, Town, or County)
Casper
813: (State or Foreign Country)
'cnning
9. Dedederit s Education
Associate Degree
10. WaS'Decedent of Hispariid'Origin? (Yes or No) If yes, specify,
No
White
12. WaS ever
Arnied'Forces':, (es
13a. Residence: Number and Street (e.g., 624 SE 5'" St.) (Include Apt. No.)
9695 Clipper Place
1 31,-. City or Town
Silverdale
13c. Residence: County
Kitsap
13d. Tribal Reservation Name (if aPplicable)
136. State or Foreign Country
lotA
13f. Zip Code 4
98383
139, Inside City Limits?
'0)). r No 0 Unk
14. Estimated length of time at residence.
20 years
15. Marital Status at Time of Death
Married
16. Surviying Spouse's or Domestic Partner's Name (Give name prior to first Merriage)
MariOn:Ekau
1
17: Usual Ocbupation (Indicate type of work done during most of working life. (Do NOT USE RETIRE(.
Machinist
18' Kind of Business/Industry (Do not use Company Name)
United States Navy
19. Fathers Name (First, Middle, Last, Suffix)
H.arold Charles Mosher
20. Mother'sNanie Before First Marriage (First, Middle, Last)
Eileen Lois Lund
21. Informant's Name
Marion Mosher
22. Relationship to Decedent
Wife
23. Mailing Address: Number and Street or RFD No. City or Town State Zip
9695 Clipper Place Silverdale WA 98383
ate;
24. Place of Death, if Death Occurred in a Hospital: Place of Death, if Death Ocpurred Somewhere Other than a'Hospital:
Inpatient
425.
Facility Name (If not a facility, give number street or location)
Harrison Medical Center
6a. City, Town, or Location of Death
Bremerton
e 6b. State 7. Zjp Code
WA 98310
28.y of Disposition
Cremation
29, Place of .Final Disposition (Name of cemetery, crematory, Othr, place)
Cherry Grove Crematory
0. Location-City/Town, and State
Poulsbo. WA
3.431.
Name and Complete Address of Funeral Facility
Lewis Funeral Chapel 5303 tsEip Way. „Bremerton.WA 98312
32:D'ate of Disposition
6-25-2009
Funeral Director Signature X
...6GrYtA/teaC-C [;22Fkr
:Cause Of.DeathISee instructions d examples)
34: Enter thechain of events diseases, injuries, or complications that directly caused the death. 'DO NOT enter terminal events such as
cardiac arrest; respiratory arrest, or
'Interval between Onsel,& Death
4, 2..rriort,)
7
ventricular fibrillation without showing the etiology, DO NOT ABBREVIATE. Add additional lines if necessary.
IMMEDIATE CAUSE (Final disease or
Condition resulting in depth) a. ek0605.Thr7v4 filt/L-71Fogi
Due to (or as .a consequence of): lnterval between Onset Death
Sequentially list conditions, if any, leading b.
to the cause listed on line a, Enter the
Due to (or as a of): IntrvaI between•onseo Death
UNDERLYING CAUSE (disease or injury
that initiated .the events resulting in c.
death)LAST Due to (or as a consequence of): Marva! between.Onset Death
d.
35. Other significant conditions contributing to death but not resulting in the underlying cause given above
36. Autopsy?
0 Yes DINo
37.;Were autopsy findings available to
completelne Cause of Death?
D Yes "UN°
38. Kenner of Death
&atural 0 Homicide
0 Accident 0 Undetermined
0 Suicide 0 Pending
39. If female
0 Not pregnant within past year a Not pregnantiOut pregnant within 42 days before death
0 Pregnant at time of death 0 Not pregnant ;butoregnant 43 days to 1 year before death
0 Unknown if pregnant within the past year
40.. Did tobacdo,use contribute
to'cleath?
0 Yes b Probably
&PIO 0 Unknown
41. Date of Injury imm000rirryi
42 Hour of Injury (24hrs)
4 Place of Injutyle.g.. home,'bonetruction site, restaurant, wooded area)
44. Injury at Work?
0 Yes .ErNo El unk,
„tot
`City
45: Location of Injury: Number Street: Apt No
or Town: County: State: ZipCode+ 4:
46. Ctescribe injury occurred
47. If transportation injury, specify':
0 Driver/Operato'r .,0 Pedestrian
0 Passenger p Other (Sp,ecify)
48a. certifying Ph sician-T 't r b Medical
-or
udli140201I
:an Adclre of Certifier Physician, Medical Examiner Pr.° r n t
Jog Johnson,, 2720 Clare Ave. t: 2
1,:Ndrne and Ale of tftending PhySiclan if other than :Certifier (Typ diP 7 '''.'"lo'
4 1J:
li 1
53. Tit eq:of 54: License NLilier i:i' l t illifrii., a 11,!, 1
146 ,i i.A 1
Examiner/COroner
c
ner.Fileo'Nqmber
9 94340W,
56. Was
tti: Deatii(24hrs),
0
q. Date prgned (MM/CD/Yo'yY)
se r fer,redlo
Ye:k
51 Registrar Signature il '"-s,„ ,r -.1' ,,---;s>
es Or 0 4
X 14, ,.-7 3
59 Amendments t
,.A...•EraTI•F^ E O'P YcF T 19;E RE,C 0 NhF. DIF 1710E ?I\ ,I Tifi•F OR H' :E4A,LeT H S 'TV+ T'd.S 7 ilE...R. T
58.
l'F I EiD g 02III:ES
s'•• 1
1 i
H 01;-003 0196
I'vl.l..1 S T., H ,0,/"F. liff. .1of', I■4 L 1. Ek
F*Nurrillar,
..f...Z,
..4(
U• Obly 7
■Tio
.1: 4.4 Alt:
T.V., Of TtaN
1PPeRfT RE T O'KHEA LT H
W4shin*.ckn SfateCerkifidate"pf)3eStp State'Pliq ber
,14, 1tWoT-A.'
1