HomeMy WebLinkAbout972615STATE OF UTAH
SS.
COUNTY OF CACHE
WITNESS my hand and official seal.
RECEIVED 8/13/2013 at 9:20 AM
RECEIVING 972615
BOOK: 817 PAGE: 699
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
I, ROSELENA ROBINSON SANDERS, being first duly sworn upon my oath, depose
and state as follows:
1. That I am a daughter of Merle G. Robinson and Clara Elenena Robinson.
2. That Merle G. Robinson and Clara Elena Robinson own real property in Lincoln
County, Wyoming as "husband and wife, by the entireties pursuant to a Warranty Deed that
was recorded in the land records of Lincoln County, Wyoming on January 8, 1976 in Book 122
PR at Page 696 as Instrument No. 473748, a copy of which is attached hereto.
3. That on September 29, 1976, Merle G. Robinson died in Bonneville County,
Idaho. An official copy of the Certificate of Death that was issued for Merle G. Robinson is
attached hereto.
4. That pursuant to Wyoming Statutes 2 -9 -102, I certify that upon the death of
Merle G. Robinson, the tenancy by the entireties was terminated and that title to the above
referenced land was then vested solely in the name of Clara Elena Robinson, a single woman.
DATED this day of August, 2013.
SUBSCRIBED AND SWORN TO before me by ROSELENA ROBINSON
SANDERS on this, the Ca day of August, 2013.
NOTARY PUBLIC
CELIA DEVASHER
My Commission 582940
My Commission Expires
June 7, 2014
STATE OF UTAH
My Commission expires: G, /7/0/,
ROSE ENA ROBINSON SANDERS
NOTARY PUBLIC
0699
DEPARTMENT OF HEALTH
2 1
TYPE, OR PRINT 114 Locm rawme.
PUMAkINI
SEE HANDIODE DECEASED—NAME
fOR
DECEASED
PARENTS
CAUSE
CERTIFIER
BURIAL
usuAL REMENICE
011111. 0ECEASE0
"Pr
.a:100
..A CERTIFICATION OF VITAL RECORDA,
ilistiactioss
20. Fj^ (3'1 on
STATE Of BIRTH 111 NOT IN U
I. Wyominr,
SOCIAL SECURITY NUMBER
12.
PART I
1
00001710110,11 A704,
W■000 0•111 RISS TO
0•1•101010 C•011 104
0101)0070 TOR *NON-
BYINO C•US1 IASI
INJURY AT WORK
622cirr .YESOR NO/
Xt.
7.15833
.04
Merle
STATE OF WYOMING
ENVISION OF HEALTH ANC/ mEDICAL. SERViCES
1976
CERTIFICATE OF DEATH
011001.1 1040 SEX DATE OF DEATH 031, ye...)
Robinson 0 Kale Sect .29,1976
RACE WI1111, 04040, •01111C•N INtnAry. AGE—up 4.10.2 1 00*! imot. 1 DAY DATE OF BIRTH I /Know, 000, COUNTY OF DEATH
ETC. 1 MGM! MONDAY 1NA.s, MOS. DAYS DOUR. I DIN. 1 1,11
4.. te 3. 67 ,Sept 1 909 Lincoln
ILL
CITY, TOWN, OOCATION oF DEATH coy. OMITS HOSPITAL OR OTHER IRRRRITUTION 004 IN 111011, 01D0 MUT AND Hummt
71 No Id At "riDne
.3.•., NAME CITIZEN OF WHAT COUNTRY MARRIED, NEVER MARRIED, SURVIVING SPOUSE 111 WIN, 01VB /4•10111 NUM I
COUN111Y1 WIDOWED, DIVORCED 1 sProrL 1
Marrierl Cla Von Elone Wol flcy
USUAL OCCUPATION lam R100 0 010 00 0001 0,4100 004001 KIND OF BUSINESS OR INDUSTRY
W0401.0 101, W.m 17 10111001
13.. Rancher 138.
100.04 cow UAW, STREET AND NUMBER
RESIDENCE—STATE COUNTY CITY, TOWN, OR LOCATION
u
SPIGOT NIS OR NO I
I dab o 14 13 o nn i v o 11. eli, Fr t:.,e on
1 HO NC 14 nOn.0
FATHER—NAME MST 11.00/1 LAP 44017444.-MAIDEN NAME 7I441
JOi Par-t Robinson I6 Rose Lutbl.
I NTORMANT —NAME
.174. JA Rebinnon.
ONLY ONE *4094 0100040 FOR (o); (137. AND (01
strwLiw:bmsp 01•111
.ADDBMIN•11 0/1.TERVAL
/9).'
DEATH WAS CALLSEO
1 lb)
DUI 10. OR 01 CONSF0O1NC10)1
1
PART II. OTHER SIGNIFKANT CONDITIONS, CONDITIONS CONTRIBUTING, ro ENNR RN Noir NUM ro cAuse GIVEN OA PAID 1 WI
PLACE 0 INJURY AT NOW, 40111, SONO, 0147001, LOCATION
tot: 209
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, VVyoming.
DATE ISSUED: AUG 6 2013
,This_copy is not validunless prepared on paper with an engraved border.
1 11110 OR 0.7.0. NO., CIO OR low*, STAYS
11•11 NIA 144041R
MAILING ADORESS 10111411 OR 4.7.0. NO., CITY OR !OWN, 11011, 071
FreedomAyoming (:3120
2480
AUTOPSY IF YES WERS 7100110S CON.
(YRS OR NO1 81011110 IN ORTERIAININO CADS!
1111, .1%
ACCIDENT, SUICIDE, HOMI0DE, DATE OF INJURY *wok. DAY, VAR) HOUR HOW INJURY OtC0RR10 IMOLA
OR UNDETERMINED
20o. 208 270. M. 204.
11.1111 of t01204 IN 4A41 1 0....? IL 111* 14)
CERTIFICATION. Au.. 000 NEE 00010 DAY MAR ANo BAST SAD( HIANNEE Amf Om 4 cnotim 001 0)10 10! DEATH OCCURREO N INE MCC orr no
PHYSICIAN: RAF-- YEAR RODE AFTER 0:0111. I NOull .3 0 0014, *00/00 OM
I me 1 A
--MEDICAL EXA I N 71.111 11, Of THE HOUR 0 01•01 i TUE DEGFOrN7 WAS 'ROHM/NM DUO
21... kickAmo iist,,,, t t o t NER OR CORONER. O y I d I O ..:111.::.5 v"/ 211 It /1-,4 214. 412_,- 1 2I. El 4 (10m..1: THE CAU $.1
CERTIFICATION
MONO. DAY 11•11
RANAIRAII0v 01 DIE 1001 AND/ DO 1..15110 ADON, IN /AY courioN
CA Al 22k M.
CERTIFIER---NAME irnvellerI TT oli vie DATE SIGNED wom., op., YEW
IGNATU
C- ....4 E.7e. r.0 11/1 23 wr- .ei
snap O. 4.2.0. NO. COY OR 1 r
MAILING ADDRESS- STAIR ZIP
224 Y 11-si N. 0 rrlie ZN
BURIAL, CREMATION, REMOVAL CEMETERY OR CREmATORY—NAME
1 MC111 I
N. Bur al TM FT' e dor: c e me t e Ty 21c Freedom elyorlin
DATE r mow., w.y. 00•111 FUNERAL HOME—NAME AND ADDRESS 1111.1 DR ...o. No CV, 011YOWN, 11•11,1111
M October 2,1976m. Schwab Mcrtua AP n Wyoming 63110
FLINERAI...AIRE9419R—SIGNATLIRE 1/ Li REGISTRAR N LOCAl REGISTRAR
1 (1)ZZAl r• t1
James McBride
Deputy State Registrar