HomeMy WebLinkAbout972929STATE OF WYOMING
ss.
COUNTY OF n a lr
AFFIDAVIT OF SURVIVORSHIP
CHESTER R. SEBASTIAN, being first duly sworn upon his oath, deposes and states as
follows:
1 On the 1 l th day of July, 2013, HILDEGARDE SEBASTIAN, died, as is evidenced by
the official certificate of death attached hereto and incorporated herein by this reference.
2. At the time of her death HILDEGARDE SEBASTIAN jointly owned certain real
property with me, said real property being located in the County of Lincoln, State of Wyoming, and
more particularly described as follows:
Lots 5, 6 and 8 of Block 43 of the First Addition to the Town of Kemmerer, Lincoln
County, Wyoming.
3. Said real property was originally conveyed to JOE SEBASTIAN, CHESTER R.
SEBASTIAN and HILDEGARDE SEBASTIAN, as joint tenants with rights of survivorship, by
Quitclaim Deed dated October 22, 2002, and recorded in the Office of the Lincoln County Clerk and
Ex- Officio Register of Deeds on October 22, 2002, in Book 502 at Page 459.
4. By reason of HILDEGARDE SEBASTIAN's death, I am entitled to sole ownership of
the above mentioned real property.
DATED this d' 6
day of
RECEIVED 8/28/2013 at 10:15 AM
RECEIVING 972929
BOOK: 818 PAGE: 853
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
4'k&%
2013.
(AL,
CHESTER R. SEBASTIAN
0853
0854
SUBSCRIBED AND SWORN to and acknowledged before me this day of
2013, by CHESTER R. SEBASTIAN.
WITNESS my hand and official seal.
My Commission Expires:
S
2
ERT ITAL RECORD
This t5:a'ttne and setae reprodacripe of the dectanent officially registered and
kid placed on file the,office of [he S�ate Regtstrar and Vital •Records.
17/2013 DEC'UTYR$GISTItAR SIGNATURE AUTHENTICATE
9 DATE ISSUED: 'Wits copy dor'vlid unlessprepa ngraved border displaying dam seal ars$ srgnatnre ofliegistraz
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VRS- Rev 201205230
PRINT IN
E1RMANENT
SLACK INK
DECEDENT
)p`n'
OCCURRED: IN
`1NSTI7U.710N
EE HANDBOOK
REGARDING
OMPLETION OF
RESIDENCE
ITEMS
REN
.SPOSITIO
LADE CALL
CERTIFIER
2EGISTRAR
CAUSE OF
DEATH
ANDITIO,N. §,jF'
ANY:WHICH:"
'SAVE RISE.:Tb
IMMEDIA'TE::•
CAUSE
'STATING THE
UNDERLYING
CAUSE LAST..
FT "inn)'+
v v
RTIFIC 4TE`'OF DEATH
201::$01 5
STATE P1I ':NUMI}ER
N
DEO„E,AS)rf3 N4ME, (FIRST,MIDDLEST,SUFFIX)
SEBASTIAN
3b CITY TOWN O t, :LOCATION'a1 DEATH'
eno
5. RACE Whi
86 STATE OF BIRT1't'ilf nfft.0 SA•;
namecoUhtry)
1:3;; ?SOCIAL SECURITY NUMBEF2..
15a. RESIDENCE STATE
Nevada
18a INFORMANT -.NAME (Typenr:Pfnt)
Alta Michele ELLIS...
14 BURIAL,,OREMATION, REMOVAL, OTHER(Specify)
Cremat
TRADE GALL NAME AND ADDRESS
DUE TO, OR AS A CONSEQUENCE OF.'
...:F:
DUE TO OR ASIA CONSEQUENCE:OF:.t
:28e•:ACC., SUICIDE, IOM:: UNDET
pg;RENDING INVEST:(Specify)
28e. INJURY AT WORK (Specify
Yes or
3c. kOSPITALOR OTHER,INSTITUTION Name(If.not:either, give::street
and number,')
Rosewood Rehabilitation •Centel'
15b. COUNTY
:W8Shoe
6. "HispanicOrigin ?Specify
No Non Hispanic
fnterval,;betwen onset;and::rleath•::
9b CITIZEN OF WHAT COUNTm
United; States
to f DUCAT)ON
14a::Usu, :;OCC:I2P'ATION (Give Kind of :Work Done Wing MOO:
of Working Ltfe Even If Retired
Rancher
15c, TOWN ORLOCATIQN'
S.un'Valley 1
16: FATHER/PARENT.:= NAME (Rust Middle 'Last :suffix)
L not' S ENCE:
20a FUNERAL DIRE>TOR SIGNATURE (Or.;Person Actingas Such)
J.OANAV BUSAM
SIGNA 'URE AUTHEN T CATER
z
a a
o 0
U z
LL
m r
0
21.5. To.the best of my knowledge, death occurred time,' date and place'and
due to (he 'cause(s.);stated.. ;(Signature, &:Title). SIGNATURE AUTHENTICATED
1ii CHRIS MAGBOO "M D
21b::DA7E SIGNED'{(Mo /Agy/Yr)
219. HOUR OE TH
tilt' 12.,.20 #3
21d. NAME OF'ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER,..
(Type or Print)
24a R!". (3
BRI DG E S SI
SIGNATURE AUTHENTICATED
25. IMMEDIATE CAUSE (ENTER ONLY•ONE CAUSE PER LINE FOR (a) (b
PART I (a) Pancreatic cancer
28bz.oATE •OPINJURY•.(Mo /4ay/Yr)
19b. CEMETERY OR CREMATORY NAME
Truckee Meadows Crematory
23a NAME "AND ADDRESS OF CERTIFIER (PHYSICIAN ATTENDINGIPHYSICio +MED CALEXAMINER ORC (Type or Print)
Mel: Christopher:Magboo D 50 Kirman Avenue #205 Reno, 89502' 7
20b FUNERAL
0 IREt TORLICENSE
DUE TO, OR AS'A'CONSEQUENCE OF:::'
(d)
OTHER SIGNIFICANT CQNOITIONS onditions oonribub ng o death bt not resulting, in the un
th u o derlyin cause, given in Part 1.
PART: C t
28c. OF INJ14R
28f. PLACE OF INJURY- At home, faun; street, fabtory Vffice
building etc. (Specify)
7a. AGE-La'st
birthday ,(Years)
81'
7b.'UNDER:1: :YEAR
MQ5 0AYS
11. MARRIED, NEVER MARRIED, WIDOWED,
DIVORCED (Specify) Widowed
24b: DATE "RECEIVED BY REGISTRAR
(Mo /Day/Yt July 16, 2013
7c.'UNDER 1 DAY
HOURS MINS
14b. KIN0.OF BUSINESS:OR.INOUSIRY:
Rariclling
15d;STREETANQ
6295 `Klikatat Co urt
17, MOTHER/PARENT NAME (First Middle Last Suffix)
Alta.. WI LSON
18b::MAILING:ADDRESS ';::(Sires .or R FcD. NO Cdy O('Town,
5855 Qoi ti Glrcle Su:n Valley;; Nevada 89433:
.0.
22b. DATE..SIGNED (Mo /Day/Yr)
z
:22d PRONOUNCED DeAD lMo /oa..iN
2. DATE'' OFDEATH:(Mo /Day/Year) `,;;`3a: COUN:f WF'DEATH
July 11, 2013 Washoe
e )f. Hosp. or In indicate DOA OP /Emer. Rm.
In(32tient(S pecify)
npatle11
4. SEX
Female
8; :DATE:OF BIRTH (MO' /Day/Yr)
112. SURVIVINGSPOUSE:(ifwife, give
1 1 maiden name)
Ever in U
Forces? No
15e. INSIDE:gn
LIMIT,S(Spec(
or No) N'ID:
19 LOCATION City or Town `State
Sparks Nevada :8943 :1''
'20c NAME AND ADDRESS OF FACILITY
Truckee Meadows Cremation and Burial
616;Soutn.,We)ls; Reno ;NV, 83502
n m :22a
Ori:theIzte0S of,eiaminatidh and/or Investigaii4rr, Iq myopmlon death occurred, ?at
-0 -'the time, date` and plane :and)duetothe cause(s) stated. (Signature,8 Title)
22c. HOUR OF DEATH
y. PRONOUNCED QEAD AT (Hour)
23b. LICENSE
.9713
YES, Q NO
24c. DEATH DUE TO COMMUNICABLE'DISEASE'
ntArval:betweert :onset;etid deettr
1 Interval between onset and death
Irterval ?aetweer):.,iinset:•;and death
26 AUTOPSY 27 WAS.'CASEREFERRED';
(Specify YSs or TO CORONER (Specify Yes;,
No or No) No
28d DESCRIB,oW INJURY:ocCURRED
28g t;OCAT10.N
STF.tERT:S R.} ;ED.:No C(•TY ORITOWit
STATE REGISTRAR