HomeMy WebLinkAbout868797GIJRLITY BUILDERS 3 R. Fax :307 977 -3300 Oct 3 'CO 12:36 P.10
Affidavit Affecting Title and Terminating Estate of Joint Tenant
I, Peter S. Wendell, being duly sworn on oath depose and state
as follows-:
1. That under the
consideration, Leisure
deed was duly filed of
clerk, on August 13,
on page 532, conveyed
husband and wife as
property, to -wit:
Lot Sixty -Two (62) in Star Valley Ranch Plat Three (3) as platted
and recorded in the official records of Lincoln County, Wyoming
2. That by reason of said conveyance aforesaid, the said Peter
S. Wendell and Lee J. Wendell, husband and wife, became the
owners of the above described land, and title thereto vested
in them continuously from the date of said conveyance in said
deed to the date of death of said Lee J. Wendell, on the 17th
day of May, 2000.
3. That Lee J. wendell and Nellie Eva Wendell are one and
the same person.
4. That by reason of and upon the death of Lee J. Wendell,
also known as Nellie Eva wendell, title to the above described
real property vested absolutely in Affiant, peter S. Wendell,
as surviving spouse.
Affiant avers and certifies that Nellie Eva Wendell, also
known as Lee J. Wendell, is the identical party named with the
Affiant in the, aforementioned deed whose death terminated her
interest, title and estate in said real property; and Affiant
attaches hereto and makes a part of this affidavit, a copy of
the Official Certificate of Death of said decedent, duly
certified by the public authority in which said death certificate
is a matter of record.
WITNESS my hand this 3a°o day of
State of /Obe f ill
county of Vf) r1117ltg' Pr.14:4
The foregoing instrument was acknowledged before me, a notary
public in and for said County and State, by Peter S. Wendell
this 3/J) day of .rx°7j 200D.
WITNESS my hand and official seal.
date of August 10, 1976, for valuable
Valley, Inc., by deed of that date, which
record in the.Office of the Lincoln County
1976, in Book 129 of Photostatic Records
to Peter S. wendell and Lee J. Wendell,
joint tenants, the following described
1 se.
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Notary Public
S
BOOK__ .J __PR PAGE 5 1 4
868797
RECEIVED
t,ra a�t
W 11�
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1. Decedent's Name (First, Middle, Last)
4 4!U
Social Security Number
1 43 -26 -666
Usual Residence of Decedent
10a. State
30. fame and address of person who comple
1. Date filed (Month, Day, Year)
32. Registrar'
MAY 2 3 2000
Ignature
4)€-
7. Age (In yrs. last birth.:
Yrs.
4b. City, Town, or
Hours
2. Date of Death
Month Day
3. Time of Death
10d. Inside City Limits
1 Maas 2DNo
DATE ISSUED:
MAY 23 2000
4a Facility Name (/f not instituti.n, g /v:
VALID ONLY
WITH
EAL IMP RESSED
S
lob. County
Broward
10e. Street and Number
8132 N.W. 15th Manor
11. Marital Status
10 Never Married 2a Marred
3 D Widowed 4 D Divorced
Elementary/Secondary (0-12)
17. Father's Name (First, Midd le, Last)
Edward Johnston
23a. Parts. Enter the disea
shock, or heart failure
Immediate Cause (Final
disease or condition
resulting in death)
Sequentially list conditions,
if any, leading to immediate
cause. Enter Underlying
Cause (Disease or injury
resulting in deh events ast
25. Was case referred to medical
frier?
1 Yes 2DNo
27. Maanoer of Death
1 ytt' atural 5 0 Pending
2 Accident Investigation
3 Suicide 6 D Could not be
4 O Homicide determined
12. Was Decedent Ever in U,S.
Armed Forces?
1 D Yes 2. No
If Yes, Give
Year or Dates:
15. Decedent's Education
(Specify only highest grade completed)
I HEREBY CERTIFY THAT THE ATTACHED IS A TRUE COPY OF A
RECORD ON FILE IN THE DIVISION OF VITAL RECORDS
Please Type or Print in Black indelible Ink. Assure All Copies Are Legible.
State of Maryland Department of Health and Mental Hygiene
Certificate of Death
Reg. No.
College (1.4or 5
Own Home
18. Mother's Name (First, Middle, Maiden Surname)
Charlotte N o,Y'r is
19a. Informant's Name/Relationship (Type Print) I
r Rural Route Number, City or Town, State, Zip Code)
Rev Peter 19b. Mailing Address (Street and Number o
Wendell /Husband 8132 N.W.
20a. Method of Disposition 1 5th M anor
20b. Place of Disposition (N ame of r Plantation, F j, 3 3 3 2 2
1 0 Burial 2 DCremation 3 Removal from State cemetery, crematory or other plece�T r or t h Ma 21
4 D Donation 5 Date 20c. Location -City or Town, Stale
❑ot (s pec i fy) Forest Y
21. Signature of Funeral ,rvice License L awn M e m Gar I
Pompano Beach
22. Name and Address of Facility F L
TU Sterling- Ashton Schwab
Funeral Home, complications that c 7 3 6 F drn o,o d _sQ r Inc
s only one cause a c sad th e death. Do not enter the mode of dying, such as cardiac te r a�� arrest,
�.]�t_Q- --M -d 21��f
j Interval Betwee
V' Onset and Death
Due to (or as a consequence of):
s� l_f- L P r D /s ,5,
f
Due to (or as a consequence of):
Part II. Other significant conditions s conlribuNng to death but not resulting in the underlying cause given in Part I.
23b. Did tobacco use contribute to the cause of death?
Due to (or as a consequence of):
Hospital:
10 Inpatient 2f Ft/Outpatient 30 DOA
28a. ate of I nj u ry 28b. Time of
Month, Day Year) Injury
11 1OYes 2DNo
28e. Place of Injury At home, farm, street, factory, office
building, eftc. (Specify)
28f. Location (Street and Number or Rural Route Number,
City or Town, State)
i 29a. Certifier a »u Physician:
red at the time, date and place, and due to the cause(s) and manner as stated. d
and manner staled.
29b. Signature and title of certifier
flan, In my opinion, death occurred at the time, date and place, and due to the cause(s)
29c. License number
use of death (Item 23a) (Type, Print)
1Oc. City, Town or Location
Plantation
10f. Zip Code
33322
13. Was Decedent of Hispanic Origin? (Specify Yes or No-
Ii Yes, specify Cuban, Mexican, Puerto Rican, etc.)
1OYes 2 CIANo Specify:
16a. Decedent's Usual Occupation
(Give kind of work done during most of working
life. DO NOT use retired)
Housewife
Year
�G�ov
4c. County of Death
Location of Depth
8. Date of Birth
(Month, Day, Year) 9 Birthplace (State or Foreign
Country)
109. Citizen of What Country?
USA
14. Race American Indian,
Black, White, etc.
Specify;
White
16b. Kind of Business/Industry
10 Yes 2DNo 30 Pr obably Jnkno yn
24a. Was an autopsy
performed?
24b. Were autopsy findings
available prior to
completion of cause
of death?
1 OYes 2 .KNo 1OYes 20 No
26. Place of Death Check o
one
Other:
4D Nursing Home 5 Residence 6 DOfher (Specify)
28c. Injuyy at 28d. Describe how Injury occurred
Wo
29d. Date sr,. ed (Mon h, Day, Year)
I 03