HomeMy WebLinkAbout972660State of WY
County of Lincoln
ss.
Debra R. Heiner, being first duly sworn upon Her oath, deposes and states as follows:
1.On the November 23, 1994, my Mother, Helen F. Williges 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 Father jointly owned certain real property with her, said
real property being located in the County of Lincoln, State of Wyoming, and more
particularly described as follows:
PARCEL 1
LOT 1 AND LOT 2 OF BLOCK 9 OF THE TOWNSITE OF BEDFORD, LINCOLN
COUNTY, WYOMING, AS SAID LOT AND BLOCK ARE LAID DOWN AND
DESCRIBED ON THE OFFICIAL MAP AND PLAT THEREOF ON FILE IN THE OFFICE
OF THE LINCOLN COUNTY CLERK.
LESS AND EXCEPT THOSE LANDS CONVEYED IN THAT QUIT CLAIM DEED
RECORDED JUNE 4, 1981 IN BOOK 177PR ON PAGE 76 OF THE RECORDS OF
THE LINCOLN COUNTY CLERK.
PARCEL 2
LOTS 1 AND 2 OF BLOCK 16 OF THE TOWNSITE OF BEDFORD, LINCOLN
COUNTY, WYOMING, AS SAID LOT AND BLOCK ARE LAID DOWN AND
DESCRIBED ON THE OFFICIAL MAP AND PLAT THEREOF ON FILE IN THE OFFICE
OF THE LINCOLN COUNTY CLERK.
PARCEL 3
LOTS 3, 4 AND OF BLOCK 16 OF THE EAST ADDITION TO THE TOWNSITE OF
BEDFORD, LINCOLN COUNTY, WYOMING, AS SAID LOT AND BLOCK ARE LAID
DOWN AND DESCRIBED ON THE OFFICIAL MAP AND PLAT THEREOF ON FILE IN
THE OFFICE OF THE LINCOLN COUNTY CLERK.
3. Said real property was originally conveyed to Max Williams and Helen F.
WiIIi by Warranty Deed, dated June 6, 1973, and recorded in the office of the
Lincoln County Clerk and Ex- Officio Register of Deeds on July 19, 1973, in Book 105PR
at Page 548 Document No. 448893
4. By reason of Helen F. Williams death, my Father is entitled to sole ownership
of the above mentioned real property.
Dated this I1
Witness my hand and official seal.
Affidavit of Survivorship
Debra R. Heiner
Subscribed and Sworn to and acknowledged before me this August 12, 2013, by Debra
R. Heiner.
Dyanna Parker Notary Public
County of 'C' State of
Lincoln Wyoming
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RECEIVED 8/14/2013 at 3:44 PM
RECEIVING 972660
BOOK: 817 PAGE: 849
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
TYPE
OR PRINT
IN
PERMANENT
INK
FOR
INSTRUCTIONS
SEE
HANDBOOK
DECEDENT
DISPOSITION
CAUSE
OF DEATH
/1. DECEDENT -NAME FIRST MIDDLE LAST
Helen Francis Curtis Williams
4. SOCIAL SECURITY NUMBER
HOSPITAL: E N
rr
Na1Mal
o 42044.07
VR 2 -89 suicide
1/89 Homicide
LOCAL FILE NUMBER
7b. FACILITY NAME Ill not inslilulion, give sheet and number)
Star Valley Hospital
B. STATE OF BIRTH (II nor in U.S.A. name country)
Wyoming
11. WAS DECEDENT EVER IN U.S. ARMED FORCES?
(Specify yes or no)
131. RESIDENCE -STATE
Wyoming
3e. INSIDE CITY LIMITS?
(Specify yes or no)
No
0
7. FATHER'S NAME P901 Midrib
Lewis E. Curtis
19a. INFORMANT -NAME (Type or Print)
kr III'
Max Williams
19c. MAILING ADDRESS
r 20a. Burial Cremation Removal
from Slate, Other (Specify)
Burial
21a. FUNERAL SE
As S
pp
2; O 2271 NAME OF A ENDING
224. DATE SIGNED (Mo. ray, Yr.
(Signature) I►
IMMEDIATE CAUSE (Final
disease or condition
resulting in death)'/
Sequentially fist conditions,
it any, leading to immediate
cause. Enter UNDERLYING
CAUSE (Disease or il'ury
That nailed events
resulting in death) LAST
29. MANNER OF DEATH
d
0 Pending
investigation
0 Could rot be
Delermned
73b. COUNTY
Lincoln
14. WAS DECEDENT OF HISPANIC ORIGIN?
(Specify no or yes-ll es, specify
Cuban, Mexican Puerto Rican, Elc.)
Ntl29s Yes (Specify)
STREET OR R.F.D. NUMBER
Box 201; Bedford, Wyoming 83112
20b. DATE (Mo. Oay, Yr.)
11/6/94
Number
Date Issued December 2, 1994
STATE OF WYOMING
DIVISION OF HEALTH AND MEDICAL SERVICES
CERTIFICATE OF DEATH
5a. AGE -Last Birthday
(Years)
71
th
2a. To eb4M al my knowledge, death Ottorr.. at 1,e lime, dale nd place a
to the ceuse(9)staled
(Signature and Tile)
24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR CORONER) (Type or Print)
30a. DATE OF INJURY
(Monlh,Day,Yeer)
Morphs
9. MARRIED, NEVER MARRIED,
WIDOWED. DIVORCED (Specify
Married
13. CITY, TOWN OR LOCATION
Bedford
DUE TO (OR AS A CON ENCE OF):
Last
DUE (OR AS A CONSEQUENCE OF):
DUE TO (OR AS A CONSEQUENCE 09:
22,. HOAR OF DEATH
5b. UNDER 1 YEAR
7a. PLACE OF DEATH (Check only one)
lien) ER/Outpatient DOA (OTHER: Nursing Horne Residence Other (Specify)
129. USUAL OCCUPATION (Give kind of work done during most
of working life, even if refired)
Housewife
CITY OR TOWN
20c CEMETERY OR CREMATORY -NAME
Bedford Cemetery
7:20 PM
YSICIAN IF OTHER THAN CERTIFIER (Type or Print)
21b. NAME OF FACILITY Number
Schw Mortuary 45
Z ART 1. Enter the diseases, injuries, or co lions Ihal caused death Do not enter IM mode of dying 00th as cardiac
or respiratory arrest, shock, or heart failure. List only one cause on each line.
PART IL OTHER SIGNIFICANT CONDITIONS- Condilons conlribulirg to death bill not related to cause given in PART I
INJURY
0116
30e. PLACE OF INJURY -AI hone, farm, street, 79070711,
office building. 01c. (Specify)
7. CITY, TOWN, OR LOCATION OF DEATH
1e MOTHER'S NAME Fksl Middle
M
Hour
Afton
0. SURVIVING SPOUSE (II wile, give maiden name)
Max Williams
15. RACE American nd'
Black, White, Em.
(Specify)
White
(Specify yes or no)
5c. UNDER 1 DAY
Minutes
2. SEX 3. DATE OF DEATH (Mo., Day, Yr.)
Female November 23, 1994
1371 STREET AND NUMBER
120. KIND OF BUSINESS OR INDUSTRY
3249 Strawberry Creek Road
Elementary/Secondary (0 -12) Cdlege (1 -4 or 5 t
12
Vera Frances Parkyn
19b. RELATIONSHIP TO DECEDENT
Spouse
STATE 2IPCOD
Bedford, Wyoming
21c. ADDRESS OF FACILITY
Afton, Wyoming
230. On the basis of examination and or investigation, in my opinion death occurred
at IM time, dale and place and due to the cause(s) staled.
lg (Signature and Title) I•
23b. DATE SIGNED (MO. Day, Yr.)
u
BO O
F
23d. PRONOUNCED DEAD (MO. Day, Yr.)
Homemaking
204. LOCATION CITY OR TOWN STATE
N\ Allen D. Carter, M •,120 Hospital Lane; Afton, Wyoming 83110
250 REGISTRAR
25b. DATE RECEIVED BY REGISTRAR (64o, Day, Yr.)
27. AUTOPSY (Specify
yes or no)
No
306. TIME OF 30c. INJURY AT WORK? 3071 DESCRIBE HOW INJURY OCCURRED
°"1 1(719'
Deputy State Registrar
STATE FILE NUMBER
6. DATE OF BIRTH (Mo., Day, Yr.)
7d. COUNTY OF DEATH
Lincoln
2372 HOUR OF DEATH
August 31, 1923
16. DECEDENT'S EDUCATION
(Specify only highest grade completed)
Maiden Surname
23e. PRONOUNCED DEAD (Hour)
Approximate
Interval Between
Onset and Death.
28. WAS CASE REFERRED TO CORONER
(Specify yes or no)
No
301. LOCATION (Strad and Number or Rural Route Number, City or Town Stale)
THIS IS TO CERTIFY that this reproduction is a true
copy of a record on file in Wyoming Vital Records
Services, Cheyenne, Wyoming.
This copy is not valid unless it bears a raised
seal and the signature of the Deputy State
Registrar is in red.
M
M