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STATE OF IDAHO
COUNTY OF BANNOCK
Dated this day of October, 2000.
State of Idaho
County of Bannock
My Commission Expires: 8' /a' Q
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6' Q AVIT
BOOK 4� PAGE
Oct 4 '00 8:51
F18
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P. 02/02
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I, Karen Badten, being first duly sworn on oath, depose and say:
That i am a citizen of the United States of America and over the age of 21 years, and
a resident of Pocatello, Idaho.
That 1 was well and personally acquainted with Elmer Thurman as described in that
certain Deed of Gift dated August 23, 1985 and recorded August 26, 1985 in Book 230PR
on page 122 of the records of the Lincoln County Clerk_
That 1 know of my own knowledge that Elmer Thurman in the above described Gift
of Deed and mentioned in the attached Certified copy of Certificate of Death was one and
the same person..
This affidavit is intended to terminate the life estate of said Elmer Thurman in the
following described property:
Lot 2 of Block 1 to the Town of Grover, Lincoln County, Wyoming as
described on the official plat thereof_
Karen Badten
The foregoing instrument was subscribed and sworn to me by Karen Badten this
'day of October, 2000.
Notary Public
Yod
DECEASED C Tr
DECADENT, r A 4153 E First Middle Last
3 r Elmer THURMAN
SEX
2 M
DATE OF DEATH (mo, day, yr)
3 .February 27, 1990
DATE OF BIRTH (mo, day, yr)
4. Oct 2, 1902
AGE -last birthday
5a. 87
UNDER 1 YEAR
UNDER 1 DAY
RACE Specify White, Black, Native
American, etc. Whit
6a.
IF NATIVE AMERICAN, Specify Tribal
Affiliation (e.g. Zia, Jicardla, Navajo. etc.)
6b.
MOS. DAYS
5b.
HOURS MINS.
5c.
DECEDENT HISPANIC?
U.S. Southwest Mexican Cuban Puerto Rican Other
6c. X No Yes Specify: Specify
EDUCATION OF DECEDENT Indicate highest grade competed
7. 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 (XIK
HOSPITAL OR OTHER INSTITUTION Name (If neither, give street and number)
6a. 5708 Aztec, N.E.
HOSPITAL: OTHER:
IN Inpatient I me Nursing Home 1 Residence Other (Specify)
II
Bb.
STATE OR COUNTRY OF BIRTH
9. Wyoming
CITIZEN OF WHAT
COUNTRY
10. U .S. A
MARRIED, NEVER MARRIED,
WIDOWED, DIVORCED Specify
11. Widowed
SURVIVING SPOUSE (If wife, give birth name)
12. N/A
WAS DECEDENT EVER IN
U.S. ARMED FORCES?
13 YES (X] NO
SOCIAL SECURITY NUMBER
14 520 09 4550
USUAL OCCUPATION (Kind of work done during most of working Ide, even if retired)
15a. Barber
KIND OF BUSINESS OR INDUSTRY
Cutting
RESIDENCE State
16a. Idaho
County
16b. Bingham
CITY, TOWN OR LOCATION
16c. Blackfoot
INSIDE CITY LIMITS?
18d r YES NO
STREET AND NUMBER OR LOCATION
16e. 262 South Shilling
ZIP CODE
16f. 83221
UNMAN
FATHER NAME First Middle Last
17. Edward Clarence Thurman
MOTHER BIRTH NAME First Middle Last
18 Mary Anna Johnson
INFORMANT NAME (Type or print)
,..Georgia T. Argyle
MAILING ADDRESS Street/RFD No City/Town State Zip
1 5708 Aztec, N.E. Albuquerque, New Mexico 87110
DIS
METHOD OF DISPOSITION
X Burial Cremation A Removal
20a.
from State Donation Entombment Other (Specify)
CEMETERY CREMATORY Name
20b. Grove City Cemetery
LOCATION City/Town State
20c. Blackfoot Idaho
SON ACTING AS S �I Sifyre
FUNERAL SERVICE LICENSEE or P
LICENSE NUMBER
21b. 4-'"'"i ER
21a. ON'
FACILITY NAME
21c. Fitzgerald and Son
FACIL TY ADDRESS Stree "FD No. City/Town State
21d. P.0. Box 36690 Albuquerque, New Mexico 87176
womolo—
CERTIFICATION
CERTIFIER'S SIGNATURE On the basis of examination and /or Office of Medical Investigator
�4(zila,, ■i: roy uNirtion uoeilt ut,GUiteu et lire time, date Tribar/Miiitary Authority
and place and r ue to the cause(s) stated.
i Certified Physician
ix
22a. PP N4 �J;ikfiaile-*
TYPE/PRINT NAME n- 4 46145-fat
22b. ADDRESS Ja /9 /L41 %fal7,V 1/
DATE.IIGNED (mo, day, yr)
sr-�
22c. 2 V
HOUR OF DEATH
22d.
PRONOUNCED DEAD (mo, day, yr)
22e. 2-Z7-4 0
PRONOUNCED DEAD (hour)
22f. 1600
MANNER OF DEATH NATURAL II ACCIDENT
226. SUICIDE IN HOMICIDE R UNDETERMINED
REGISTRAR' SIGNATU
23a. a-4,--1.-.4-4--40.---
DATE FILED (Mo., Day, Yr.)
23b.- .2 as^� sr___ C
A SE OF DEATH
WAS AN AUTOPSY PERFORMED?
24a. YES NO
If yes, were findings considered in determining cause of death?
24b. YES NO
LOCATION WHERE AUTOPSY WAS PERFORMED (CITY, STATE)
24c.
WAS RECENT SURGICAL
PROCEDURE PERFORMED?
25a. (III YES NO
IF YES, SPECIFY TYPE OF PROCEDURE
25b.
DATE OF PROCEDURE
25c.
WAS DECEDENT PREGNANT
WITHIN LAST 6 WEEKS?
26a. it YES NO
If yes, estimated
length of pregnancy
26b.
DESCRIBE HOW INJURY OCCURRED (COMPLETE FOR ACCIDENT, SUICIDE, HOMICIDE, UNDETERMINED)
27a.
HOUR OF INJURY
27b.
DATE OF INJURY -(MO, DAY, YR)
27c.
INJURY AT WORK
27d YES NO
PLACE OF INJURY Specify home. farm, street, etc.
27e.
LOCATION Street/RFD No. City/Town State
27f.
28. PART I. Enter t e diseases, injuries,
w arrest, shock, or heart
O
it a IMMEDIATE CAUSE (Final
Q disease or condition y
J 2 Z resulting in death
or complications which caused the death. Do not enter the mode of dying, such as cardiac or respiratory Approximate Interval
failure. List only one cause per each line. Between Onset and
�a Death
J1y7
'�j 111 tilt l id t§6 fi"�i7CJlG,- /V i) t
4747L'& O (OR AS A CONSEQUENCE 09:
f c.Lt t& (36 X7)
z N Cr) Sequentially list =talons,
N w if any, leading to Immediate
w a cause. Enter UNDERLYING
a. CEO CAUSE (Disease or In)ury
CC U which Initiated events
O N resulting in death) LAST
Q a
w �1
DUE TO (OR AS A CONSEQUENCE OF):
c 1
DUE TO (OR AS A CONSEQUENCE On:
d.
a PART II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I.
F- 2
United States of America State of New Mexico Vital Statistics
CERTIFICATE OF DEATH Certified by Medical Investigator i yy
(NOTE: If death due to accident, suicide, homicide, trauma, Certified by Physician lJ
or unknown causes. refer case to Medical Investigator)
STATE OF NEW MEXICO
COUNTY OF SANTA FE
22368M
CERTIFIED COPY OF VITAL RECORD
This is a true and exact reproduction of the document officially
registered and filed with Vital Records and Statistics,
Public Health Division, Department of Health.
01573
Bernalillo
County of Death
307941
A Yb4 erque
City, Town, Location
etty L. Rieman
State Registrar
DATE ISSUED 111111FER 1991