HomeMy WebLinkAbout972197STATE OF WYOMING
ss.
COUNTY OF LINCOLN
AFFIDAVIT OF SURVIVORSHIP
Lot 1 of Block 1 of the Second Addition to the Town of LaBarge, formerly
Tulsa, Lincoln County, Wyoming LESS AND EXCEPT the following
described parcel:
Commencing at the southwest corner of Block 12 of the First Addition to the
Town of LaBarge, formerly Tulsa and running thence N 00°14' E, 770.00 feet
to a point on the south boundary line of Block 1 of the said Second Addition
to the Town of LaBarge;
thence S 89 °46' E along the south boundary line of said Block 1, 605.60 feet
to the true point of beginning of the description;
thence S 89 °46' E along the south boundary line of Block 1,154.40 feet to the
southeast corner of said Lot 1 of Block 1;
thence N 0°14' E along the east boundary of said Lot 1 of Block 1, 134.40
feet to a point on the center section line of Section 6, T26N, R1 12W said
point, also, being the northeast corner of said Lot 1 of Block 1;
thence along the center section line of said Section 6, N 89 °56' W, 154.52
feet;
thence S 0°11' W, 133.95 feet to the true point of beginning
RECEIVED 7/25/2013 at 10:19 AM
RECEIVING 972197
BOOK: 816 PAGE: 387
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
0387
I, JALANE WILSON, being of legal age and first duly sworn, deposes and says as follows:
1. That Jay Eugene Edmison, also known as Jay E. Edmison, the decedent mentioned in the
attached certified copy of the certificate of death, is the same person as Jay E. Edmison
named as one of the parties in that certain Quitclaim Deed dated April 23, 2012, executed
by Jay E. Edmison, a married man, sole owner of the described property to Jay E. Edmison
and Jalane Wilson, as joint tenants with rights of survivorship, recorded as Receiving
#964329 on April 30, 2012, in Book 785 at Page 369, of the Official Records of Lincoln
County, State of Wyoming, concerning the real property situated in the County of Lincoln,
State of Wyoming and described as follows:
2. That I am the same Jalane Wilson mentioned in the above referenced Quitclaim Deed and
thereby am a person interested in the effective property or the title thereto and pursuant to
2 -9 -102 W.S. (1980) hereby make the death a matter of record and certify that upon the
death of Jay Eugene Edmison, also known as Jay E. Edmison, his previous estate in the
property was terminated.
3. That the certified copy of the certificate of death indicates that Jay Eugene Edmison, also
known as Jay E. Edmison died on the 19 day of May, 2013 in the City of Phoenix, County
of Maricopa, State of Arizona.
Dated this
STATE OF WYOMIN9
�c�ytc ss.
COUNTY OF 1CO
day of July, 2013.
KAREN S. WENZ
Notary Public
Sublette County
Wyoming
My Commission Expires I
ANE WILSON
T1 is Affidavit of Survivorship was subscribed and sworn to before me by Jalane Wilson.
this 2L( T" day of July, 2013.
NOTARY PUBLIC
My Commission Expires:
2
z4
/7)/.)6/(
0388
1.. DECEDENT'S LEGAL NAME (FIRST., LAST)'
'JA EUGENEEDMISON
12. PLACE OF DEATH HOSPITAL:
INPATIENT' alE.R./OUTPATIENT
14.'FACILITY NAME (OR STREET ADDRESS IF NOT A FACILITY)
-BANNER GOOD SAMARITAN MEDICAL CENTER
17.8IRTHPLACE (CITY AND STATE OA FOREIGN COUNTRY)
`'HAYES CITY; KANSAS'
20: DECEDENT'S USUALRESIOENCE•STREET ADDRESS:
6945'E :MAIN ST.' #2227''
25. WAS DECEDENT OF HISPANIC ORIGIN'S
NO;'NOT SPANISH; HISPANIC OR LATINO
YES, MEXICAN, MEXICAN AMERICAN, CHICANO
❑'YES; PUERTO RICAN
YES, CUBAN
❑'YES; OTHER (SPECIFY)',..
28.000UPATION:....
<'OIL- FIELD WORKER':
29. FATHER'S NAME (FIRST, MIDDLE, LAST)
`CHARLES HENRY EDMISON
31, INFORMANT'S NAME.,
DONNA JEAN EDMISON
34. NAME AND ADDRESS OF FUNERAL FACILITY:.
AT. SEASONS END MORTUARY 861, W. SUPERSTITION' BLVD,
JUNCTION;-AZ
37. METHOD(S) OF DISPOSITION: 38 :NAME AND LOCATION OF 1st DISPOSITION FACILITY:
'CREMATION, SAGUARO VALEY.CREMATIONSERVICES, MESA, ARIZONA'`
ro0 ,C 41;," As 4 t• rts.§s,Rtii ';t0,;,:>?a?t, -.0, ,t,.MEDICAL CERTIFICATION SECTICN;CAUWOF, PART,1A
IMMEDIATE CAUSE :u. A
OF DEATH
INTRACRANIALBLEEDING; F..
DUE,TO OR AS A,
CONSEQUENCE'OF:.
DUE TO OR AS A
CONSEQUENCE OF:
DUE TO OR AS A
CONSEQUENCE OF:
5 :.SOCIAL• SECURITY NUMBER:
•.CAUSE•OF DEATH PART II•*dt,•rot+i t,
I': ■9 SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING
IN THE UNDERLYING CAUSES GIVEN ABOVE:
57. CERTIFIERS ADDRESS:
1111 ;E MCDOWELURD' PHOENIX AZ 85006
13. PLACE OF. DEATH OTHER THAN HOSPITAL:
CARE I FACIL HOME OR LONG TERM El RESIDENCE HOSPICE FACILITY ❑OTHER.
18. MARITAL STATUS AT TIME OF
DEATH:
MARRIED
32:RELATIONSHIP"
SPOUSE
26. DECEDENT'S RACE(S):
23 WHITE.
BLACK, AFRICAN AMERICAN
NATIVE HAWAIIAN
OTHER ASIAN,(SPECIFY),,,,,,,
ASIAN INDIAN
CHINESE
FILIPINO
-JAPANESE
'GUAMANIAN OR CHAMORRO
'KOREAN
VIETNAMESE ❑UNKNOWN
•SAMOAN
AMERICAN INDIAN`OR'ALASKA NA71VE:,
OTHER PACIFIC ISLANDER (SPECIFY)
15. CITY, TOWN 8 ZIP CODE CR LOCATION OF DEATH:..
PHOENIX 85006
19. NAME OF SURVIVING SPOUSE (MAIDEN NAME IF
DONNA JEAN NELSON:
:79'- b0.k={+
23. ZIP CODE.
85207.
18. COUNTY OF DEATH:
MARICOPA
24:EVER IN THE .ARMED
FORCES'
NO'
27. IF AMERICAN INDIAN OR ALASKA NATIVE.
SPECIFY UP TO 4 TRIBES..
PRIMARY OR ENROLLED TRIBE:
ADDITIONAL TRIBE:
30. MOTHER'S NAME (FIRST; MIDDLE, LAST NAME PRIOR TO FIRST MARRIAGE)
w,;; t
33, INFORMANT'S MAILING ADDRESS:
6945' MAIN'iST #2227, MESA;•ARIZONA 85207
35: FUNERAL,DIRECTOR:
:CHRISTINA FUNERAL. DIRECTOR
39..NAME-AND LOCATION OF 2nd DISPOSITION FACILITY:
ti r.
r yv,�,." w.
41: APPROXIMATE INTERVAL;
UNKNOWN
43. APPROXIMATE INTERVAL:
UNKNOWN
51. MANNER OF DEATH
NATURAL DEATH
COMPLETE THE CAUSE OF DEATH?
58. NAME OF REGISTRAR:
MICHELE CASTANEDA MARTINEZ
45. APPROXIMATE INTERVAL:
47. APPROXIMATE INTERVAL:,
52.-TIME OF DEATH',
'1740
53. WAS AN AUTCPSY PEFFORMED7 54 :WERE. AUTOPSY FINDINGS AVAILABLE. TO
'ATRIAL FIBRILLATION;: CHRONIC OBSTRUCTIVE PULMONARY DISEASE NO
�Xt P(: c mt 44,- ,Oix,, ts{r.} c CAUSE AND MANNER OF• DEATH CERTIFICATION;
181 'Certifying Physician/Nurse Practitioner/Physician's Assistant To the best of mV 55. NAME OF PERSON COMPLETING CAUSE OF DEATH:.
knowledge death occurred due to the cause(s) manner stated.
MedIca Exa ner/Tribal Law Enforcement Authority "On the basis of examination,
and/or investigatlon,zin my opinion, death occurred at the time, date, and place, and
;due to the cause(s)and'mannerstated MCIHAMMAf1 AI I NI t(1 ANI lAn
55. DATE REGISTERED:
:05/2272013
STATE OF ARIZONA
DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS
CERTIFICATE OF DEATH e File
State Fil:NO. .102 2013 020611
PATRICIA ADAMS
ASSISTANT STATE REGISTRAR
:This isa true certification of the facts on file with the OFFICE OF VITAL RECORDS,
ARIZONA'DEPARTMENTOF HEALTH SERVICES, PHOENIX; ARIZONA.
':Revised 04/2010-
l .This copy not valid' 'Unless prepared on a form displaving the State Seal and impressed with the raised'seal' the issuing agency'
ANY ALTERATION OR ERASURE VOIDS THIS DOCUMENT v*
1 %i.%:•r ��FS;." fir pi. %gc,I Z0f •1a
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