HomeMy WebLinkAbout972270AFTER RECORDING MAIL TO:
Kelly S. Davis
Attorney at Law
408 West 23r Street, Suite 1
Cheyenne, Wyoming 82001
CHARLOTTE M. ASPENGREN, the undersigned Affiant, being of legal age
and being first duly sworn on her oath according to law, deposes and states as
follows:
1. That she is the undersigned CHARLOTTE M. ASPENGREN, who is
named as one of the Grantees of a joint tenancy with DAVID L. EVERETT, in that
certain warranty deed executed on July 12, 1989, by LEISURE VALLEY, INC.,
Grantor, and recorded on August 14, 1989, in Book 276PR, Page 345, of the official
records of the Clerk of Lincoln County, Wyoming, concerning that certain real
property situated in the County of Lincoln, State of Wyoming, and more particularly
described as follows:
Star Valley Ranch Plat Eighteen (18) Lot One Hundred Thirty -Nine
(139) as platted and recorded in the Official Records of Lincoln County,
Wyoming.
2. That the DAVID LEE EVERETT mentioned as the decedent in the
attached Certificate of Death is the same person as the DAVID L. EVERETT named
in the above referenced Deed.
3. That all the estate and interests of said DAVID L. EVERETT in the
above described real property as created under said vesting instrument terminated
by reason of his death on September 3, 2012, leaving the undersigned,
CHARLOTTE M. ASPENGREN, the sole and absolute owner of said real property.
Further the Affiant sayth naught.
DATED this 12 day of
STATE OF IDAHO
COUNTY OF C)c
RECEIVED 7/29/2013 at 11:43 AM
RECEIVING 972270
BOOK: 816 PAGE: 595
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
ss.
2013.
CHARLOTTE M. ASPENGREN Affiant
SUBSCRIBED AND SWORN TO by the Affiant, CHARLOTTE M.
ASPENGREN, before me this \a_ day of )v,,\t 2013.
Witness my hand and official seal.
NOTARY PUBLIC
My Commission Expires: Se1. 22 2011
0595
TYPEnR
PRINTw
::PERNARENT.
H DEATH WAS
DUE TO OTHER
:THAN %WAAL
CAUSE9
:THE CORONER
'Stat'e
CERTIFICATE. OF DEATH 6TATEFiLE 07824
09/05/2012 vewADOW WWII GGCIIAEST csaTEIYa FS WE A'K:I(EdetbA arnl OE DEPARWESTOf HEALTH ANOWDEARE
AWED L AuurA iisfo Ya114E FADS em SKEDsmm vEA.N WSW WAT WAFo DARE, EAS ,f Local Reif: ,the
GATE FI(,ED DY'STATE REGISTRAR:;
It FOR AN"
PLACE OF
DEATH
DATE OF
DEATH
II3r' 5
TO HC USED
OR LA
CAI SLS ONI.3
1.12ECEDENT'S LEGAL NAME (Include AKA's if any) (FlnL Middle, Lest, Suffix)
DAVID:•LEE EVERETT'
41.AOE- Lasl:elntlday'`.
416UNDER 1 YEAR
Monthe,;j Days
Ta. RESIDENCE STATEOR COUNTRY
4C. TINDER 1: DAY
5,,o4: simian OF DISPOSITION.-
Den4
:P .0 Bu4a1:: ®:C1.91n0
0 1IPn E
O 0 Removal from Idaho
2 0 Other Specify)
17e,.EIGNATURE OF FUNERAL SERVICE UCENSEE OR PERSON ACT1NO AS SUCH
Y F FILED;:'SCOTT'1N..CORNELISON
23. DATE OF DEATH (MOIDay/Yr) (Spell month)
September. 3.2012:.
332 PATE OF INJURY:(Mo)Dey/YO
(5pia m6hlh)
Septelnber3 2012.:
3 TIME'O
Eo ma( 00 01 02
00
8.:0A?E OF BIRTH:(Mo)DFy)Y()
01113/1944
BANNOCK
t 7d. STREET AND NUMBER
;(155 CANYON;RD
SIMARITAL'STATUS AT TIMEOF DEATH:
b c N Me01411 M80ed, bu11824 led 0: V4dowe ONorcod 0 Never inertled Uriknovm'
r 10 EVERIINU0 11i.,FAYHER'S NAMEIFIreL.Mlodle, Last, Suffix)
:5'7 19ei INFORI4 print)
Ac HARL O TTE M. ASPENGREN c�
136. RELATIONSHIP TO DECEDENT
PERSONAL REP
16 PLACE OeCISPOSITION (HAM and address M ce)ne(
crem1wy;:the 06
SOUTHEASTIDAHO.
BLACKFOOT IDAH083221;.
24. TIME OF DEATH 124hr1
Estimated 00:01.02:00
6. BIRTHPLACE (City and State, Territory, or Foreign Country)
IDAHO FALLS IDAHQ
70. CITY OR' TOWN
POCATF140
7e. APT. NO.,
12a. MOTHER'S MAIDEN NAME (Fest Middle, Lasl,Su
..BETTY JEANNE WILHITE
LICENSE NUMBER (Of. liCensee)
M0829
PART 11.- Enter other sionfficarg.condibon.s conMhutine to death 6th not resulting In I n
DEPRESSION
30. IF FEMALE (Aged 10 -E4)::
O NIA pregnant within pail year O No1'plegnant, butpregnanl43.08y3
O Pregnant at time of death lolyear before deem
No pregnant, b4(.pregnan(, 0 Unknown If pregnant within the past
wllhm'42 dayp:al death _Year
MALE
3;SOCIALSECURITY NUMBER
70.1NSIDE CITY
®Vee'.: zCy .100'
9.SURVIVING SPOUSE'S NAME (If vide, give maiden name)
11b:,,eurr99LACE(Slets Tepltory wroreign
IDAHO
(26,'BIRTIIPLACE.(Sl4ler. )'erdlory;91
IDAHO
130. MAILING ADDRESS (Street and Number, City, Stale, Lp Code)
P.O. BOX 4340 POCATELLO, ID 83205
16. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
CORNELISON HENDERSON FUNERAL HOME
431 NORTH':15TH:AVENUE
POCATELLO., IDAHO 83201
101 WASCORONER CONTACTED
DUE TO CAUSE OF DEA78171
Yes. ❑N0'(`
`.::PLACE OF DEATH (19 -22)
19s';IF DEATH OCCURREDIN 19b. IF. DEATH' OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:,.. v
YDtnpellent 2 0ER/OUteetleut 90DOA 4 0HctPfce 1 Illyi6'O Nursing horde1Long tone can.i, Illty 61pDec84 0 1150)e' 70 Other(Speciy)
20.FACIUTY NAME (II DEt fe10)ly;:0l00 sVee(Nnp numpery
155 CANYON RD.
+21. CITY;JOWN, ORLOCATIONOF.DEATN;ANDZIP'CODE; 22 cquNTY OF DEATHl,
POCATELLO 10 83204 BANNOCK'
26. DATE PRONOUNCED DEAD(MgIDay/Yr).(Spell month)
September 3, 2012
27..CAUSE OF DEATH
PART I. Entetihe. eNNn of MANES 41ge0Ees,1 (1(1160 oi.omplicatlena -that directly speed eleeeellr. DO,NOT. enter tanninalayeets such es cardiac
eSlyest, msp114iory ONeat OnY6)Ndculgr•110NIletlon ahovilnB me etiology: DO NOTABBREVIATE. Erder.only onecauseori:a Ilea
IMMEDIATE CAUSE (Fln I„
disease or POhUlUOn a PENETRATING;IIEAD',TRAUMA
rekul0ng in death) DUE TO:(or a a:000 69uence 00:
Sequengelty list conditions, b GUN SHOT WOUND'
m lfa (ea
rV, dhp ro the cause WE TO (w es a consequence oft.
Ileled, IIna e. Enter the I
•UNDERLYIND.CAUSE
:LAST,1OIaoao9:or bnjury
iN me'ewM s
!reselling In,0660)
D es a COn OD:
Approximate Interval:
...Onset to pear;
'IMMEDIATE
IMMEDIATE
34. PLACE OF INJURY (Decedents home, farm; street, constmcgon site, 1 36. INJURY AT WORK?
nusingNane tas ry 1 fo rasl elct
HOME d ®.No
F 36. LOCATION OF INJURY:
IX Slate:3DAHO
W Street and Number or Location 155 CANYON RD.
V 37 •DESCRIBE.HOW INJURY OCCURRED. IF TRANSPORTATION INJURY, STATE THE TYPES(S) OF VEHICLE(S) INVOLVED (AUlomoblle; p ckup mohecycle ATV bicynle;erela)-
SPECIFY•' WHICH. VEHICLEUECEDENT.000UPIED; O applicable
$ELF +INFLICTED GUNSHOT :TO :HEAD
TRANSP,DRTATION :3Ba WAS DECEDENT O',Ddver/Ope101 0 PAasenger 1181 SAFETY DEVICES(S) DID DECEDENT USE /EMPLOY?
INJURYONLV. i :.0 N 0 d Fg3'0
'i O':Pedes6taR D OI)?.eY (Specify) OSeat belt.' Child: safe :seal Helmet:: Alrb None' .,0 Unknown
City/Town arCounty POCATELLO BANNOCK ze'boda 83204'
'39a. CERTIFIER (Check only one, based :en.of0clat capacity for this rerllfiCate)
0 PHYSICIAN' 0 PHYSICIAN ASSISTANT 0 ARVANCEO PRACTICE PROFESSIONAL NURSE
-To the best of my knowledge, death occurred al the Um dale, and'plabe, and duel o lli:Al IaW .caliee(s)Imamer RAMC
IEII. CORONER
On the'.besis f examination and/or Investigation, In my opinion, death occurred at the time, dale and place, end due to the cause(s)
..and manner rated
:glgritera j0d TItle 09Ceriin v,' ELECTRONICAL SIGNED!'. KIM QUICK
28;.TIME pRONOUNCED
''i 124110"
09:00
230: WAS 'AN AUTOPSY: 29b.)NERE LA AUTOPSY FINDINGS
PERFORMED? AVAIBLE TO COMPLETE
'THE:CAUSE OF DEATk7
p Yas .N O Yes Ne
!31 MANNEROFDEATH
0 N lurel 0 Hbmlcide
0 Accident trending Investigation
ca Suicide 0 Could not be determined
39b; LICENSE NUMBER:-
360. NAME, ADDRESS, ANDZIR CODE OF CE RTIFIER(1'ype cr:pdnt)
KIM QUICK 1760 SATTERFIELD DRIVE POCATELLO ID 83201
REGISTRAR'S SIGNATURE
401, :DATE SIGNED "b i....
2012
This is a trUR.and correct reproduction of the document officially registered and placed
On file with the IDAHO 'BUREAU OF VITAL R ECORDS AND .HEALTH STATISTICS.
lH
AT t....
0 I
t r
11 \L" Il
R D i
f �r r This copy nut valid unless prepared on engraved border,
displaying etatesea) and signature of the Registrar.
PSNCO) )9L12•
DATE ISSUED:
ST ATE OF IDAHO
`IDAHO DEPARTMENT OF HEALTFI AND WELFARE
BUREAU OF VITAL RECORDS`ANDiHEALTa :STATISTICS•.
'914%1114
L ID
AI
.Vn
VALI
AT
W.11 III QM MI [Imp
CERTIFICATION OF VITAL RECORD