HomeMy WebLinkAbout869767STATE OF WYOMING
ss.
COUNTY OF LINCOLN
AFFIDAVIT OF DEATH OF COTENANT
Recorded if l.�. Q. at S A M
In Book Page 64.4. Kemmerer, WY
No, Jeanne Wagner, Clerk
LueDene C. Jenkins, of PO Box 82, Afton, Wyoming 83110, and upon her oath
deposes and says:
1. That Ruel E. Jenkins, the decedent mentioned in the attached copy of
Certificate of Death, is the same person as Ruel E. Jenkins named as one of the grantees
in that certain Warranty Deed dated the 11 day of October, 1964, executed by Lathair H.
Call and Ree Bruce Call, husband and wife, grantors, to Ruel E. Jenkins and LueDene C.
Jenkins, husband and wife, by the entireties, grantees, and recorded October 20, 1964, as
Instrument No. 385385 in Book 68 of PR, page 212, of the Official Records of Lincoln
County, Wyoming, covering the following described real property located in Lincoln County,
Wyoming, to -wit:
Beginning at a point 5 rods South from the Northwest Corner of Lot #2 of
Block #7 in the Town of Afton, Lincoln County, Wyoming, and running thence
East 10 rods, thence South 5 rods, thence West 10 rods, thence North 5 rods
to the point of beginning, together with improvements and water rights.
2. That the undersigned affiant is the same identical person as LueDene C.
Jenkins, named as one of the grantees in the above described Warranty Deed, that she
and Ruel E. Jenkins were husband and wife at the time of the execution and recording of
the Warranty Deed described above, and that as the surviving cotenant and spouse of
Ruel E. Jenkins, named in said conveyance, the undersigned, LueDene C. Jenkins,
became on April 9, 2000, the date of the death of the aforementioned decedent, the owner
of the lands or the owner of any interest of Ruel E. Jenkins in the lands described in the
foregoing, subject to any then existing liens and encumbrances.
DATED the 7 day of November, 2000.
1
LueDene Jenkins
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STATUS
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CE OFDFATH 1CI180ronn.?nsi
OTHER
3' DOA 0 Nursing Home u 6. Residence 7. Other
$d' COUNTY OF DEATH
12a. DECEDENTS USUAL OCCUPATION (Give kind of
during most of working life. Do NOT use retired)
WAiDECEDENT or HISPANIC ORIGIN? 0 i y. 432 2 No
(:v SP�i,Y)
5. RACE Black, While, Am. Indian
(Tribe may be entered), Japanese,
aa9� rryy etc. (Speedy)
u 1 rye3 2 No 110 i Me icen' 2. C ohen 3.Pueno (Scan 4. Other Specib) wails
1k FATHER N,M r6G'L1eo k„ Sol) 18. MAIDEN NAME OF MOTHER (First, Middle, Last)
fJ r ANNIE MABEL ERICKSON
fyAk1 t}ELAT1 h3I faAJ9 t9, (1A P3 ESS INF ¢,RMANT
'WIDE,C 82, ANON, WYOMING, 83110
MF04100 P Y1 N 2 fj AA1pt7P'DISPOSITION 21b. PLACE OF DISPOSITION (Name of
1 &Ftbmbm,4nL
CAUSEOF DEATH (ITEM 31) (Type /Prim)
/03V! 4/ sC.C2 4e) Provo u7' C/620s
9. SURVIVING SPOUSE (d wll8.glv0 maiden name)
LUEDENE CAZIER
3a. DATE OF DEATH (Mo. Day Yr.) 3b. TIME OF DEATH
APRIL 9, 2000 2350
r F 7 OCIAL SECURITY N
BIRTHPLACE (City d State or Foreign Country) UMBER
FREEDOM, WYOMING 520-24 -4783
85. NAME OF HOSPITAL NURSING HOME OR OTHER FACILITY (If outside a facility.
give sheet address of location)
UTAH VALLEY REGIONAL MEDICAL CENTER
830907 E FL{ Af SERVIC)E ICBNSE 23 LICENSEE NUMBER 24. FUNERAL HOME (Name, address and license number)
221144550902 811023890901 BERG MORTUARY
S T Y S S r 4 185 EAST CFNTP�tt STREE.
AT C A 4 (j`f. N not Coked by medical examiner, was death reposed to M.E.?
All BY CERRTIFYING PHYSICIAN II a en ter the date and hour r 1. VesXJ 2. No CVO, LAH 84606 j� ry� y reported M.E. Case No.
T �r!/ HOUR MO. DAY YEAR
CERTIF E
i To the best ot,my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner as slated.
2..;RIF' ITAL,RAW' I A WE61F0R PMENT OFFICIAI On the basis of examination and /or investigation, in my opinion. death occurred at the time,
Sato, place, and uer tqe cafae {s) and manner as stated.
300. DATE REGISTRAR NOTIFIED OF DEATH (Mo.,Day, Yr.) 300. DATE FILED (Mo.. Day, Yr.)
APR 1 1 21_
PART )f Other g4i50 nj con ib bog to f(p'at9 bat ndi 32. IN YOUR OPINION, TOBACCO USE BY THE DECEDENT 33a. WAS AN 334. WERE AUTOPSY
esUlbd9 the uncler(yi 0 61(009ke f I Past 0 1 Probably contributed to the rouse of death. 5. NON -USER AUTOPSY FINDINGS AVAILABLE
PERFORMED? PRIOR TO COMPLETION
a r/�'f iii 2. Was the underlying cause of death.
OF CAUSE OF DEATH?
Z3. Did not contribute to the cause of death. 6. UNKNOWN t� Yes 2 No j} Z (40
4. Is unknown in relation to the cause of death. IF USER 1 1
34, MANNER OF D A7
35a; DATE TNJUSY WO. Day Y[) 350. TIME OF INJURY 35c. INJURY AT WORK? 35d. PLACE OF INJURY At home, farm, Street, factory.
i' N414,4,, (24 Hour Clock) office, bui(ding,etc. (Speedy)
1.Yes ❑2. No
Oy (St rjet or rural route number, dry 0, town, money and stare./ 35f. If motor vehicle accident specify 0 decedent wa
3. Suicide 4 H¢nVole driver, passenger or pedestrian.
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This i to certify that this le at
under authotity of section 26 2
STATE OF UTAH DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
)O MPLIC A T( yin
0- i)r� O�PLIG�Y(ONS THAT CAUSED THE DEATH, DO NOT ENTER THE MODE OF DYING, SUCH AS CARDIAC
IT3QK t5R 1ART FAILURE 'LIST ONLY ONE CAUSE ON EACH LINE.
g: T9'0 'I(SACONSEOUENCE OF):
(SUE TO (Ol3 AS A CONSEOUENCE OF):
Tet (OR (19 A CONSEOUENCE OF):
SC`t(BE HOW1NJU,3Y OCCURRED (enter sequence of events which resulted in injury, NATURE OF INJURY SHOULD BE ENTERED IN ITEM 31)
H1g6
e cog of the certificate on file in this office. This certified copy is issued
?2 Af e, Jtah 'Code Annotated, 1953 As Amended.
Barry E. Nangle
;DIRECTOR OF VITAL RECORDS
6. EDUCATION (Specify only highest grade
completed) Elementary or Secondary
(0 -12) College (13.16 or 17 s)
Approximate Interval'
Between .Onset and
Death,
DEPARTMENT OF HEALT
WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES EN
'T ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATION if.