HomeMy WebLinkAbout972738STATE OF WYOMING
SS
COUNTY OF LINCOLN
RECEIVED 8/20/2013 at 9:57 AM
RECEIVING 972738
BOOK: 818 PAGE: 327
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
1
Shari M. Grissom, first duly sworn, upon oath, deposes and says:
1. Shari M. Grissom is the widow of Danny D. Grissom and has knowledge
of and is competent to testify concerning the facts as stated below.
2. Shari M. Grissom and Danny D. Grissom were married to each other and
they lived together as husband and wife in Lincoln County, Wyoming continuously until
the death of Danny D. Grissom.
3. Shari M. Grissom and Danny D. Grissom owned, as tenants by the
entireties, the following real property as indicated by the attached Warranty Deed
recorded as Document No. 770309 at Book 334PR, Page 339 in the Lincoln County,
Wyoming Clerk's Office, Kemmerer, Wyoming.
4. On July 21, 2000, Danny D. Grissom died in Lincoln County, Wyoming
Attached is a Certified Copy of his official Death Certificate certified to by the State of
Wyoming, Department of Health.
5. By reason of the death of Danny D. Grissom on July 21, 2000, Shari M.
Grissom became the sole owner of the above described property.
6. Shari M. Grissom is the Grantor of the GRISSOM FAMILY LIVING
TRUST LIVING TRUST DATED APRIL 22, 2013. By this affidavit, I, Shari M.
Grissom, hereby direct that the above referenced property be transferred and titled in the
0327
name of Shari M. Grissom, Trustee, or her successors in trust of the GRISSOM FAMILY
LIVING TRUST LIVING TRUST DATED APRIL 22, 2013.
7. This transfer is completed upon the exchange of sufficient consideration,
the receipt of which is hereby acknowledged.
8. I hereby waive all rights pursuant to the homestead laws of the state of
Wyoming.
DATED: this 7" j-day of April, 2013.
Subscribed and sworn to before me by Shari M. Grissom this day of
April, 2013.
Witness my hand and official seal.
JACK D. EDWARDS NOTARY PUBIC
COUNTY OF STATE OF
WYOMING
MY COMMISSION EXPIRES
My commission expires: OII(q Zol
2
-747
Shari M. Grissom
NOTARY PUBLIC
0
w•S
TAL RECORD'
LOCAL FILE NINBER
OR PRINT QR
1. DECEO-NAME FIRST 1RODIE (AST 01A4414 FEN 71 1NENT D 64.X.S ►0+
O rT
FOR 4. SOCIAL SECURITY NUMBER
EIS7KUCTIOMS
HANDBOOK T• PLACE OF DEATH (Choc* only m.)
❑■1. ol 00 0N 4 .l DDOA t1ER t Husk, Nam n. 8 DSw(sy.gly).. ACCIDENT. SCENE
DECEDENT
INFORMANT
DISPOSITION
CAUSE
OF DEATH
13.7510E CITY LAATST
(SP•FDY WE a no)
NO
iinza 17. FATHERS NAME FFFI
EARLON
CERTIFIER
FACILITY NAME (n!nol 1,5111111006a. dR alder =abr.)
U.S. 89 MILEPOST 76`:85
STATE OF RAMP/ not A, Da A. AMme aan2Y)
WISCONSIN
1.1. W)SDECFDEM EVER NUS ARMED FORCES,
(swdry ys a nal
NO
1L RESEENCE• STATE
WYOMING
12d NFORMANT- NAME(ryp 07 Pang SHARI GRISSOM
19c UAIJNO ADDRESS
BOX 5207
saa ButiA Qmsttlort Remo.'
M211112•18, 01Mr DOWN)
NS0E2k Pena Acting limber
UPDATE RID (MO, Ory. Yr.) I 22o. HOUR OF DEATH
Seaenlisty tN madden.
11 .np WAN IF 1,2.4400
aemi.Ee. twooaY1q
EAU* brLm 1.Y
eal 'uR ow mai.
IeWtt12 11M5 LAST
LINCOLN
STREET OR RFD.
STATE OF WYOMING
DIVISION OF HEALTH AND MEDICAL SERVICES
CERTIFICATE OF DEATH
19. WAS DECEDENT OF 118RNIIC ORION?
126sce2 00 ye.S yoo s2l2
<;Cdrt Uakart PmM Ram sto
DUE, TO )00 AS A CONSEOUENCEOF):
Tc. OITY, TONINI'.GR LOCATON QF DEATH
MILEPOST' 76.85
'0 SURVMNO SPOUSE 01 alto, On maiden lams)
SHARI BENSHOOF
120U5t1AL'OCCUPATION /6We Maki 1 000* deed d5A2 Mast
a/ 4w0Al2 21s, aid., N rmasa)
MECHANIC
OO CITY, TOWN OR LOCATION
ETNA
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.'P1 dm I.rl.dau:Plld5tigpnd4. d m
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a
2217 NAVE OF ATTFJDIND PHYSICIAN F OTHER THAN CERTFER(Typs ar A*N)
2e. NAME AND ADDRESS OF CEATFIER (PHYSICIAN OR COROIER) (rypa or Ri.I)
9 P 1 1 t;v) G'.• Di* IWob f• fO 40/,‘ 84
21111REGISTRAR
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26. or Rfpelery..l.t sheds mh.rt 06.6. list any me muss on edl Dm.
111111FFIATE CANCAN,/
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,.siding in d:Nh) 4
°DEW AS A DORcEaDEN,E On:1
Last
GRISSOM
200 QEAE1F112 OR CNEM07027 -NAME
ETNA CEMETERY
PARTS OTIQi SIONFICANT COADITONS•Cond0an conYNWYq Is death but rat misled to aegis Ono 21 PMT I
7- 2/- 00 /Ph
tee. PLACE OFNANiy:ino*, en;a.At wen.
dIm:O■n2 Na (27.277)
U. S. HIGHWAY 89
14 MOT12.8 NAME
ALLENE
STATE
:WYOMING
tad STREET AM NUMBER
COUNTY RD. 115 961 CLARK LANE
22a DATE SIGNED (7,, Dry. W.)
2S1PRO40IA1CIOI1EA4(M.. Diy.. Y,.)
0 DATE OF DEATH(Mr, Dry. W.)
100. RIND OF 9US7FBt OR IMUST111
SELF- EMPLOYED
74 CQOHTY'OF DEATH
LINCOLN-
2061002TDN
2170 ADDRESS OF FACRITY
44 EAST FOURTH ;,.AVE., AFTON
J x c f t C v o L I d 3 a V I
04
Malden Gram.
LANGDON
CRY TOWN
ETNA
a!rnPS f/.`(�YJ
J ames McBride
Deputy State Registrar
T.
2k HOUR OF DEATH
200LOCATION Moat 2.0007210,71,5172. Namb.i or Taon;Ststal
MILEPOST ,76..
0
4s ,i( :bi {1 Eli c lSg:
CERTIFICATIO
7.:'7155_
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming.
DATE ISSUED: AUG 1 5 2013
This copy is not valid unless prepared on paper with an engraved border.
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