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Home My WebLink About971541State of WY County of Lincoln ss. Sandra S. Hampshire, being first duly sworn upon His /Her oath, deposes and states as follows: 1.On the March 21,2013, my husband, John Gary Hampshire passed away, as is evidenced by the official certificate of death attached hereto and incorporated herein by this reference. 2. At the time of death my wife /husband jointly owned certain real property with me, said real property being located in the County of Lincoln State of Wyoming, and more particularly described as follows: ALL OF LOT 14 OF THE STAR VALLEY RANCH PLAT 3, LINCOLN COUNTY, WYOMING, FILED MARCH 3, 1971 AS INSTRUMENT NO. 428885 IN THE OFFICE OF THE LINCOLN COUNTY CLERK. 3. Said real property was originally conveyed to John G. and Sandra S. Hampshire, husband and wife, by Quit claim Deed, dated August 18, 2012, and recorded in the office of the Lincoln County Clerk and Ex- Officio Register of Deeds on August 21, 2012, in Book 792 at Page 103. 4. By reason of John G Hampshire death, I am entitled to sole ownership of the above mentioned real property. Dated this June I ,2013 Subscribed and Sworn to and acknowledged before me this `l day of June, 2013, by Sandra S. Hampshire. Witness my hand and official seal. RECEIVED 6/18/2013 at 4:14 PM RECEIVING 971541 BOOK: 814 PAGE: 3 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY Affidavit of Survivorship Sandra S. Hampshire Notary P C Commis Expires: (S. 7 `d 0 003 DATE ISSUED: 04 /04/2013 STATE OF ARIZONA DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS CERTIFICATE OF DEATH Cf... CII. At^ This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS, PATRICIA ADAMS ARIZONA. DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA. ASSISTANT STATE REGISTRAR Revised 04/2010 This copy not v unless prepared on a form displaying the State Seal and impressed with the raised seal of the issuing agency, rvFi /oiTi 9 iepir1111ent of Health Services CERTIFICATION OF VITAL RECORD ..•awac uc iW. J ZU13- U1Z /1.7/ 1. DECEDENT'S LEGAL NAME (FIRST, MIDDLE, LAST) 2. AKA'S (IF ANY) 3. DATE OF DEATH JOHN GARY HAMPSHIRE MARCH 21, 2013 4. SEX 5. SOCIAL SECURITY NUMBER: 6. DATE OF BIRTH 7. AGE UNDER 1 YEAR UNDER 1 DAY 8. MONTHS 9. DAYS 10. HOURS 11. MINUTES MALE 01/05/1936 77 12. PLACE OF DEAT HOSPITAL: 13. PLACE OF DEATH OTHER THAN HOSPITAL: INPATIENT E.R. /OUTPATIENT DEAD ON ARRIVAL NURSING HOME OR LONG TERM RESIDENCE CARE FACILITY NI HOSPICE FACILITY OTHER 14. FACILITY NAME (OR STREET ADDRESS IF NOT A FACILITY): 15. CITY, TOWN ZIP CODE OR LOCATION OF DEATH: 16. COUNTY OF DEATH: HOSPICE OF THE VALLEY SURPRISE PCU SURPRISE 8379 MARICOPA 17. BIRTHPLACE (CITY AND STATE OR FOREIGN COUNTRY) 18. MARITAL STATUS AT TIME OF 19. NAME OF SURVIVING SPOUSE (MAIDEN NAME IF WIFE) DEATH: OGDEN, UTAH MARRIED SANDRA SUE SCHABERG 20. DECEDENTS USUAL RESIDENCE STREET ADDRESS: 21. CITY AND COUNTY: 22, STATE 23. FOR ZIP CODE 24. EVER iN S THE ARMED CE 252 MAHOGANY WAY THAYNE, LINCOLN WYOMING 83127 YES 25. WAS DECEDENT OF HISPANIC ORIGIN? 26. DECEDENTS RACE(S): 27. IF AMERICAN INDIAN OR ALASKA NATIVE. NO, NOT SPANISH, HISPANIC OR LATINO WHITE OTHER ASIAN,(SP.EC FY) SPECIFY UP TO TRIBES. CI YES, MEXICAN, MEXICAN AMERICAN, CHICANO BLACK AFRICAN AMERICAN PRIMARY OR ENROLLED TRIBE: CI YES, PUERTO RICAN ❑NATIV HAWAIIAN ASIAN INDIAN OTHER PACIFIC ISLANDER (SPECIFY) YES, CUBAN CHINESE ADDITIONAL TRIBE: YES, OTHER (SPECIFY) FILIPINO El JAPANESE OTHER (SPECIFY) CI GUAMANIAN OR CHAMORRO ADDITIONAL TRIBE: UNKNOWN KOREAN 28. OCCUPATION: ID VIETNAMESE CI UNKNOWN SAMOAN ADDITIONAL TRIBE: MAJOR APPLIANCE AMERICAN INDIAN OR ALASKA NATIVE 29. FATHER'S NAME (FIRST, MIDDLE, LAST) 30. MOTHER'S NAME (FIRST, MIDDLE, LAST. NAME PRIOR TO FIRST MARRIAGE) MELVIN EARL HAMPSHIRE MARY NADINE ARRINGTON- 31. INFORMANT'S NAME 32.RELATIONSHIP 33. INFORMANTS MAILING ADDRESS: SANDRA SUE HAMPSHIRE SPOUSE P 0 BOX 8S THAYNE, WYOMING 83127 34. NAME AND ADDRESS OF FUNERAL FACILITY: 35. FUNERAL DIRECTOR; 36. LI SMART CREMATION OF ARIZONA, LLC 6812 E THOMAS RD., NUMBER: SCOTTSDALE, AZ SCOTT PREWITT, FUNERAL DIRECTOR F1424 37, METHOD(S) OF DISPOSITION: 38. NAME AND LOCATION OF 1st DISPOSITION FACILITY: 39. NAME AND LOCATION OF 2nd DISPOSITION FACILITY: CREMATION LIFEPLAN CREMATORY, PHOENIX, ARIZONA lii it i!tq� MEDICAL' CgRTIF„ICATION SECTION CAUSE CF' DEAsTH PA iT i Pi Z IMMEDIATE CAUSE 40: A 41. APPROXIMATE INTERVAL. OF DEATH, MYELODYSPLASIA .7 UNKNOWN DUE TO OR AS A 42. B 43. APPROXIMATE INTERVAL: CONSEQUENCE OF: DUE TO OR AS A 44. C 45. APPROXIMATE INTERVAL: CONSEQUENCE OF: DUE TO OR AS A 46. D 47. APPROXIMATE INTERVAL: CONSEQUENCE OF: .ro; CAUSE OF DEATH PART t[ 48, OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING 49 .,INJURY? 50. INJURY AT WORK? 51. MANNER OF DEATH 52. TIME OF DEATH It' THE UNDERLYING CAUSES GIVEN ABOVE: r NO NO NATURAL.DEATH 1150 ENDSTAGE RENAL DISEASE, DIABETES MELLITUS, ATRIAL `53• WAS /NAUTCPSYPERFCRMm? 54. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? FIBRILLATION NO z CAUSE AND MANNER OF DEATH CERTIFICATION Certifying Physician/Nurse practitioner/Physician's Assistant To the best of my 55: NAME OF PERSON COMPLETING CAUSE OF DEATH: 56. DATE CERTIFIED: knowledge, death occurred due to the cause(s) and manner stated. Medand i/oc r al inv Ex n, I bal n my Law opinio Enforcemen ndeath t Authorioccurred ty at th O e n the time basis date, of and pla examination due to the causes) and manner stated. SUKHJIT SINGH 03/22/2013 57. CERTIFIERS ADDRESS: 58. NAME OF REGISTRAR: 59.DATE REGISTERED 13640 N. PLAZA DEL RIO BLVD., PEORIA, AZ 85381 MICHELE CASTANEDA- MARTINEZ 04/01/2013 ii DATE ISSUED: 04 /04/2013 STATE OF ARIZONA DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS CERTIFICATE OF DEATH Cf... CII. At^ This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS, PATRICIA ADAMS ARIZONA. DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA. ASSISTANT STATE REGISTRAR Revised 04/2010 This copy not v unless prepared on a form displaying the State Seal and impressed with the raised seal of the issuing agency, rvFi /oiTi 9 iepir1111ent of Health Services CERTIFICATION OF VITAL RECORD ..•awac uc iW. J ZU13- U1Z /1.7/ 1. DECEDENT'S LEGAL NAME (FIRST, MIDDLE, LAST) 2. AKA'S (IF ANY) 3. DATE OF DEATH JOHN GARY HAMPSHIRE MARCH 21, 2013 4. SEX 5. SOCIAL SECURITY NUMBER: 6. DATE OF BIRTH 7. AGE UNDER 1 YEAR UNDER 1 DAY 8. MONTHS 9. DAYS 10. HOURS 11. MINUTES MALE 01/05/1936 77 12. PLACE OF DEAT HOSPITAL: 13. PLACE OF DEATH OTHER THAN HOSPITAL: INPATIENT E.R. /OUTPATIENT DEAD ON ARRIVAL NURSING HOME OR LONG TERM RESIDENCE CARE FACILITY NI HOSPICE FACILITY OTHER 14. FACILITY NAME (OR STREET ADDRESS IF NOT A FACILITY): 15. CITY, TOWN ZIP CODE OR LOCATION OF DEATH: 16. COUNTY OF DEATH: HOSPICE OF THE VALLEY SURPRISE PCU SURPRISE 8379 MARICOPA 17. BIRTHPLACE (CITY AND STATE OR FOREIGN COUNTRY) 18. MARITAL STATUS AT TIME OF 19. NAME OF SURVIVING SPOUSE (MAIDEN NAME IF WIFE) DEATH: OGDEN, UTAH MARRIED SANDRA SUE SCHABERG 20. DECEDENTS USUAL RESIDENCE STREET ADDRESS: 21. CITY AND COUNTY: 22, STATE 23. FOR ZIP CODE 24. EVER iN S THE ARMED CE 252 MAHOGANY WAY THAYNE, LINCOLN WYOMING 83127 YES 25. WAS DECEDENT OF HISPANIC ORIGIN? 26. DECEDENTS RACE(S): 27. IF AMERICAN INDIAN OR ALASKA NATIVE. NO, NOT SPANISH, HISPANIC OR LATINO WHITE OTHER ASIAN,(SP.EC FY) SPECIFY UP TO TRIBES. CI YES, MEXICAN, MEXICAN AMERICAN, CHICANO BLACK AFRICAN AMERICAN PRIMARY OR ENROLLED TRIBE: CI YES, PUERTO RICAN ❑NATIV HAWAIIAN ASIAN INDIAN OTHER PACIFIC ISLANDER (SPECIFY) YES, CUBAN CHINESE ADDITIONAL TRIBE: YES, OTHER (SPECIFY) FILIPINO El JAPANESE OTHER (SPECIFY) CI GUAMANIAN OR CHAMORRO ADDITIONAL TRIBE: UNKNOWN KOREAN 28. OCCUPATION: ID VIETNAMESE CI UNKNOWN SAMOAN ADDITIONAL TRIBE: MAJOR APPLIANCE AMERICAN INDIAN OR ALASKA NATIVE 29. FATHER'S NAME (FIRST, MIDDLE, LAST) 30. MOTHER'S NAME (FIRST, MIDDLE, LAST. NAME PRIOR TO FIRST MARRIAGE) MELVIN EARL HAMPSHIRE MARY NADINE ARRINGTON- 31. INFORMANT'S NAME 32.RELATIONSHIP 33. INFORMANTS MAILING ADDRESS: SANDRA SUE HAMPSHIRE SPOUSE P 0 BOX 8S THAYNE, WYOMING 83127 34. NAME AND ADDRESS OF FUNERAL FACILITY: 35. FUNERAL DIRECTOR; 36. LI SMART CREMATION OF ARIZONA, LLC 6812 E THOMAS RD., NUMBER: SCOTTSDALE, AZ SCOTT PREWITT, FUNERAL DIRECTOR F1424 37, METHOD(S) OF DISPOSITION: 38. NAME AND LOCATION OF 1st DISPOSITION FACILITY: 39. NAME AND LOCATION OF 2nd DISPOSITION FACILITY: CREMATION LIFEPLAN CREMATORY, PHOENIX, ARIZONA lii it i!tq� MEDICAL' CgRTIF„ICATION SECTION CAUSE CF' DEAsTH PA iT i Pi Z IMMEDIATE CAUSE 40: A 41. APPROXIMATE INTERVAL. OF DEATH, MYELODYSPLASIA .7 UNKNOWN DUE TO OR AS A 42. B 43. APPROXIMATE INTERVAL: CONSEQUENCE OF: DUE TO OR AS A 44. C 45. APPROXIMATE INTERVAL: CONSEQUENCE OF: DUE TO OR AS A 46. D 47. APPROXIMATE INTERVAL: CONSEQUENCE OF: .ro; CAUSE OF DEATH PART t[ 48, OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING 49 .,INJURY? 50. INJURY AT WORK? 51. MANNER OF DEATH 52. TIME OF DEATH It' THE UNDERLYING CAUSES GIVEN ABOVE: r NO NO NATURAL.DEATH 1150 ENDSTAGE RENAL DISEASE, DIABETES MELLITUS, ATRIAL `53• WAS /NAUTCPSYPERFCRMm? 54. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? FIBRILLATION NO z CAUSE AND MANNER OF DEATH CERTIFICATION Certifying Physician/Nurse practitioner/Physician's Assistant To the best of my 55: NAME OF PERSON COMPLETING CAUSE OF DEATH: 56. DATE CERTIFIED: knowledge, death occurred due to the cause(s) and manner stated. Medand i/oc r al inv Ex n, I bal n my Law opinio Enforcemen ndeath t Authorioccurred ty at th O e n the time basis date, of and pla examination due to the causes) and manner stated. SUKHJIT SINGH 03/22/2013 57. CERTIFIERS ADDRESS: 58. NAME OF REGISTRAR: 59.DATE REGISTERED 13640 N. PLAZA DEL RIO BLVD., PEORIA, AZ 85381 MICHELE CASTANEDA- MARTINEZ 04/01/2013