HomeMy WebLinkAbout971905STATE OF COLORADO
SS.
COUNTY OF EL PASO
I, WILLIAM LEE FLEMING, being duly sworn under oath, state as follows:
1. That Donna Davis Fleming and I, as wife and husband, had tenancy by the
entireties in real property located in Thayne, Lincoln County, Wyoming, more particularly
described in the Warranty Deed that was recorded in the Lincoln County, Wyoming land records
on May 1, 2006 in Book 618 at Page 468 as Receiving No. 917966, a copy of which is attached
hereto.
2. That Donna Davis Fleming, also known as Donna Jean Davis, died on April 27,
2012. Attached hereto is an original copy of the Certificate of Death issued for Donna Jean
Davis (Fleming).
3. That pursuant to Wyoming Statutes 2 -9 -102, I certify that the tenancy by the
entireties of Donna Davis Fleming has been terminated by her death and that title to the above
referenced land is now in the name of William Lee Fleming, a single man.
DATED this W day of
WITNESS my hand and official seal.
My Commission expires: 1
RECEIVED 7/10/2013 at 9:51 AM
RECEIVING 971905
BOOK: 815 PAGE: 292
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
2013.
WILLIAM LEE FLEMING
ACKNOWLEDGED, SUBSCRIBED AND SWORN TO before me on this 111 day
of 1 L ,u 2013 by WILLIAM LEE FLEMING.
2
Auburn, California 95603
CERTIFICATE OF DEATH
STATE'0F CALIFOPNN
USE BULK RIN ONLY /NO ERASURES,WNREONTS On ALTERATIONS VSil4
ITAL RECORD
AO e n'eYRC�I'Q4mi e v ,1^ ce1Q.y�0-e�4 d��a g
1. NAME OF DECEDENT- FIRST (Given)
DONNA
2. MIDDLE
JEAN
AKA. ALSO KNOWN AS Include lull AKA (FIRST, MIDDLE, LAST)
9. BIRTH STATE/FOREIGN COUNTRY
ALABAMA
13. EDUCATION Highest Levet0egrse
hae Wmksneel on basal
MASTER'S
10. SOCIAL SECURITY NUMBER
11. EVER IN U.S. ARMED FORGES?
(ORS. WAS DECEDENT HISPANICAATINO)AYSPANISNT Pyre( see
YES
eel whack) 171 NO
12 MARITAL STAT US/SRDP hl
MARRIED
eel MPH
7. DATE OF DEATH mnedd/cRI
,04/27/201
15. DECEDENTS RACE- Up 10 01.1es May 66EAl9d (sesamailleel OA Bid()
.WHITE
17. USUAL OCCUPATION- Type of work tar most. ol. Me. DO NOT USE RETIRE0 18. KING OF BUSINESS OR NOU5TRY (e.g.. grocery store, road 6022166162, emplbyMM1'agency..;216
COUNSELOR I PUBLIC EDUCATION
19 TEARS I9 OC; CUPATION
20:
20. DECEDENT'S RESIDENCE (Street and number, or location)
o. 2204 LIVE OAK CT
21. CITY 22. COUNTY/PROVINCE .23, 2)7 CODE 24 YEARS IN COUNTY; 25. STATE/FOREIGN CWNTRY
ROCKLIN PLACER 95765 0 CALIFORNIA
26. INFORMANT'S NAME. RELATIONSHIP 27. INFORMANT'S MAILING ADDRESS Gst 9600 010l40number, Gey IoAo Mil end dp)
ASHLEY JONES, DAUGHTER 2204 LIVE OAK CT, ROCKLI 'CA 9q765
28. NAME OF SURVIVING SPOUSE/SROP' -FIRST 29. MIDDLE 30.1650(8)076 NAME)
UNKNOWN UNKNOWN
31. NAME OF FATHER/PARENT -FIRST 32, MIDDLE 34. BIRTH.STATE
MICHAEL CECIL CONNERS AL
35. NAME OF MOTHER/PARENT -FIRST 26. MIDDLE 37, LAST (BIRTH NAME) 38, BIRTHSTATE;
ANITA BETH HANKE IL
STATE FILE NUMBER
05/02/201
COUNTY OF PLACER
1 II IE1E011 HI I i �rur
CERTIFICATIO
SCATTERED OVER THE WATER OF LAKE TAHOE
DOUGLAS COUNTY, NV
41. TYPE OF DISPOSITION(S) 42. 51GNATURE OF EMBALMER 13. LICENSE NUMBER
CR/TR/SCAT NOT EMBALMED
44. NAME OF FUNERAL ESTABLISHMENT 45. LICENSE NUMBER 46. SIGNATURE OF LOCAL REGISTRAR 47 mMdd/ooyy
HERITAGE OAKS MEMORIAL CHAPEL
061990 ►RICHARD J. BURTON, MD 05
101. PLACE OF.OEATI4
er In 102.10 HOSPITAL, SPECIFY ONE 103; IF OTHER THAN HOSPITAL; SPECIFY ONE
SUTTER ROSEVILLE MEDICAL CENTER ER0 DOA hospice ®NW kg TC III iii any
Hmle/L Home
104, COUNT/ 105. FACILITY ADDRESS OR LOCATION WHERE FOUND (SlrNlund 2002600, or localron) 106 CITY
PLACER 1 MEDICAL PLAZA RO.SEVILLE
107.0005000 DEATH E I lhd 9002 1 eVI -0100 mimes. 9410n7Ara6m2. Mal t 001y 00010ddealh. 00 NOl'8,94 40600 and IMheblrwl80e4M +OLOEAJNPEP0R0ED.T0
azcNd 0rre3Lr espraloryenes1 .aln1n7J>hbnWlgnti3Ou1.Ewoo6 C2010logg. NOT ABBREVIATE 5000592006
IMMEDIATE CAUSE w CARDIOPULMONARY ARREST rFS No
(FmM 0920on rezuNin20 or NiOIL CgMNl Nraxw4lNNBae
In death) HRS
18) ACUTE MYELOID LEUKEMIA do 99elwsrPERFORMED?
Sap 11 6y Ysl
leading lePs; lanv. MOS IN YES X No
Lp0 (C) (01) 112 AUTOPSY PERFORMED?
UNDERLYING
CAUSE (disease or ®,yES x' No
Injury Shat
i ialed the events NI (OT) III USW R OET EANINI NGOAt'SE1
W11n9 In death) LAST
112.OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESU Enter 4 T HE UNDERLYING CAUSE GIVEN IN 107
NONE
1 13. WAS OPERATION PERFDRMEO TOR ANY CONDITION IN ITEM 107 OR 112101 yo..I0l type 010000.060 and dale.) 112AIF FEMALE PREGNANT IN UST YEAR/ NO
II YES X NO UNK
111I CERTIFr THAT TOTHE BESTOF DEATH OCCURRED 115, SIGNATURE 82400019 OF CERTIFIER 116UCENSE NUMBER 117 OAT( AIM/del/cm
AT7HE HOUR ,DATE. M2 PLACE5IATE5GRDM IIJECAUSE65TATE0. 1,,,..._.,,
neredrun M.:6 d i.,ala.. 4,, JACOB GUSTAV HOOVER M.D. A1173 05/0112012`-
(A) Mdd/ccyy (B) mMdd/ccyy 118. TYPE ATTENDING PHYSICIAN'S NAME, MAH.INGA0 COOE JACOB GUSTAV HOOVER M D.
04/21/2012 04/27/2012 1 1 MEDICAL PLAZA, ROSEVILLE, CA 95661
11B.ICEfiEY THAT INMYORNIONDEATH OCCURRED AT THE I HOUR, DAE, M0 PLACE STATED FROM111E CAUSES STATE0 120. INJURED AT WORK? 121, INJURY DATE n m%ddkoyy 625. HOUR (24606,0
MANNER OF.OEATH Nalual Accident l 1 Homicide I I Suicide ParldrIg DAM Ca not be 005 NO UNK
Irneslgalwn da(am6ee
723. PL.�EdF INJURY (e.D., home, construction sde, wooded area: etc)
124. DESCRIBE HOW INJURY OCCURRED (Events which resulted in Injury)
125, LOCATION OF INJURY (Street and number, 00 )0601100, and 1,08, 000 21p)
126. SIGNATURE OF CORONER/ DEPUTY CORONER (27, DATE 9Mdd/cryy 128. TYPE NAME, TITLE OF CORONER DEPUTY CORONER
STATE ,A B I C I E III�IIIIIIIflIgIIIQIIIUIUIIIIIIIIIIIIII�IhIItlIIIIIIIIIVIIIIIIIIIIIIIIIIIgI FAX'AUTHM TR
cENSUSACT
REGISTRAR I I I
•ataoo 002053861'
CERTIFIED COPY OF VITAL.RECORD.S
STATE OF CALIFORNIA, COUNTY OFPLACER
4xs;4„ aZS,vae„ r�¢$g,4,,;:'�'4aY4b ;�cip }o'�bTSre�S�hai7 4Aaebos
4v440944Wriov r0 03P'200The4 0.4S-0.4) ihtiTVaP(L
This is a true and exact reproduction of the document officially registered and placed.
On file in. the office of the Placer County Health and Human Services Department.
8 q Richard J. Burton,'
DATE ISSUED 1 2 I 1 8 2012 HEALTH OFFICER AND LOCAL. REGISTRAR
This copy is not valid unless prepared on an engraved border displaying the date, seal and signature Izf.Registrar
"ink, PBNCO(ROOS/II
LOCAL REGISTRAT)ONNUMBER
BIRTH Ea DEATH FETAL DEATH
TYP EOR PRINT CLEARLY IN BLACK INK ONLY THIS AMENDMENT BECOMES AN ACTUAL PART OF THE OFFICIAL RECORD
PART I INFQRMATION TO LOCATE RECORD
18. NAME —FIRST
DONNA
2. SEX
F
18. MIDDLE
JEAN
3. DATE OF EVENT— MMIDD /CCYY
04/27/2012
6. FULL NAME OF FATHER/PARENT AS STATED ON ORIGINAL RECORD
MICHAEL CECIL CONNERS
INFORMATION
AS IT APPEARS
ON ORIGINAL,
RECORD
PART I1 STATEMENT OF CORRECTIONS TO BIRTH, DEATH ETAL DEATH RECORD
8. ITEM: 9. INCORRECT INFORMATION THAT APPEARS ON ORIGINAL RECORD 10 CORRECTED INFORMATION IT SHOULD APPEAR
NUMBER TO BE
CORRECTED
UNKNOWN
UNKNOWN
LIST ONE
ITEM PER
LINE.
REASON FOR
CORRECTION
AFFIDAVITS
AND
SIGNATURES
TWO
PERSONS
MUST SIGN
THIS FORM TO
CORRECTA
BIRTH, DEATH;
OR FETAL
DEATH
RECORD
3052012081648
STATE FILE NUMBER
71 TO CORRECT THE. RECORD
We, the undersigned, hereby certify under penalty of perjury that we have personal knowledge of the above facts and
that the information given above is true and correct:
128. SIGNAT E OF FIRS 8680 128.
/N �l eG William PRINTED NAME Fleming
12D. ADDRESS (STREET and NUMBER. CITY. STATE, OP)
12645 Angelina Drive, Payton, CO 80831
13A. SIGNATURE OF SECOND PERSON
on
13D. ADDRESS (STREET GMbER, CITY, STATE. ZIP(
2204 Live Oak C Rocklin, CA .95765
STATE /LOCAL, 14. OFFICE OF VITAL RECOROSOR LOCAL REGISTRAR
REGISTRAR STATE REGISTR AR OFFICEOF VITAL RECORDS
USE ONLY
II pn II n� d
STATE OF'CALIFORNIA,DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDS In111I11II1II1II11W11111I1IV111 1tl1 11III11IIIII111IfI'�ltl11IiI1I1IU1III1IUI1; FORM. VS 24.e.(REV. 1(08)
11
CERTIFICATION OF VITAL RECORD
3, e e 3 e b a a a e <`a b o eR b RXv Re eA 9 za. ova MWT:V'.s a
COUNTY OF PLACER
Auburn, California 95603
AFFIDAVIT TO AMEND A RECORD
NO ERASURES, WHITEOUTS PHOTOCOPIES,
OR ALTERATIONS
4. CITY OF EVENT 5 COUNTYOE EVENT
ROSEVILLE PLACER
7. FULL NAME OF MOTHER/PARENT AS STATED ON ORIGINAL RECORD
ANITA BETH,.HANKE
WILLIAM
FLEMING
This is a true and exact reproduction of the document officially registered and placed
on file in:the office of the Placer County Health and Human Services Department.
IC. LAST
DAVI
32012310.01.096
LOCAL REGISTRATION' NUMBER
138. PRINTED NAME
Ashley Jones
CERTIFIED COPY OF VITAL RECORDS
STATE OF CALIFORNIA, COUNTY OF :PLACER
12C.T1TLE(RELATIONSHIP TO PERSON IN PART 1
Husband
(2E. DATE SIGNED MMIDO/CCYY
13C. TITLE/RELATIONSHIP TO PERSON IN PART I
Daughter
13E DATE SIGNED MM /DD /CC.YV
o aaoa
15. DATE ACCEPTEDFOR: :REGISTRATION
10/01/2012
.`0201010021321$..
1:fi
Riche d J. Burton; M;D.
DATE ISSUED
1. 2 11` 8 2012 HEALTH OFFICER AND LOCAL REGISTRAR
This copy is not valid unless prepared on an engraved border displaying the date, seal and signature of Registrar.
PINCA (IUV) 08/11
a f 4 4444 V V 40.00 AY'fTJO 4434 a A 4V.1 OWV: q'i i'VV4V 0 •fYe a 40060. ifCk� p "j jyoi ap di r'�`r(,P.n�
TH THIS DOCUMENT IS PINK THE BACK OF THIS DOCUM MT 10 01 II AND HAS AN ARTIFICIAL WATERMARK HOLD AT AN ANri r Tn EW
November '28,: 2012'
o
rte 'ere
1 1 01 5
to lim
8eat,'No r�
r Wn Ile RiR;AL)A 4 i
give
Do Not'oVs3te
Qj :1
Beat No..4_
E city or t
F. Ix end Box No.)
me only)
and clAYs)
0
ere
r 'Cain to br
S �IPt' tENTA RY
:Q n9 20
bY,.�CI'k
6 'Date o1' trtb 'i 18 T
(UH y6) 1 (Year)
9 ?:111 name_.f�fr.L_
ite 'or 11 A at
c ii iime
a3
12 `Btrthplat a
or •wi
Reg. Dis Cer(1Xt
trier Na o b cato No
T ftllcd, out by looal registrar
A
1i Colored race
Wh pt.Lpi s birch
n
13':Full aine e'a
'before
.rnarrtpge
11: White or 16. Agtairne
Colored race of this bWih_...pGf2... yra
6�
lei
(Citty or'Town) (Co, y) to orfforelgn country)
pt (a) Cldren born alive and, at time ibis j
W bir lncluding this child
this child was. born alive but.: died
Y
alter birth, consider It as living et
n :a t of thle
t�! (b) Preolous. children borlive bu# de d at limo
(0) Previous children born dead (stillborn)
Total nitntber, 1noiUdligg this birth
<AdQi
19 .1 hereby eertlfy that 1 a rt dad the b(rth of tills ohll b orn alive
at.the hourioL4_ �1: on the elate stated bove Th. iii
e tion given was furnished b
r1 •red o 1
11
/0
1
ifs or
(State
th
Fife No. for State
Registrar only
forel_ ii- dGnitY)
Department of Commerce
Bureau of the Census
CERTIFICATE OF L BER
BTATE OF ALABAMA BUREAU bF VITAL STATISTICS
STATE. 110A.fl Oa Bt A.LTx
IPPtCETOF $tRTK
City or: "fawn f
(If .outside car
ll 01 0lty o
Street addressJ..'l t
f11
(T in h pi r.''tnst tutiOni
:Length 0 *Other"B stay before delivery 0
tSpeolfy:.in years,
2. 'USUAL REBID NCE OF 14OTHER
State
County ..,;.le�l
City or e n
(If outs' e corporate 11
Street
(If rural:ve
S. FU L AME OF CHI
4. )rib ori'iatr)'7
'.(Months;of pregnancy)
Full term
/fJ
Center far'.Heait
Twin or triplet
If so —born, la 2d .or
7..Ie mother
merrlad to father..
of this
19. Mother a ling address for birth notification
Suppp]ensatary data below aro not apart a�
th e legaltcertl[icsit'
A,i: Was a 61ood test:fdr syphilis
made on t) c r other of
;this cull duritt$ ='preenancy
B, Congenital malformations?
?bo of 1teHeri
statistics
whose address
Attendants
own sign
Date 'signed 1
0 2
r (Month by name) :(Year)
A4dress
SC
20. Received_.. 19...
Leal deput
reglst ar a
cleft !t< ��,Az BSS]]]
(SpeGlfy w)icihe Ciul3foot, cieft palate, cte) owt� switature_.__
This certificate mwustbe tiled with lees registrar within five (5) days actor birth
r
This As. .an official certified -copy of the original record filed in the Center of Health
Stat]st` cs::, Alabama D`ep::artment.:of Public Health,': Mon.tgtimery, Alabama 2012. 442:888 :9
C atherine Mole han Dd
State Registrar of Vital Statistics'