HomeMy WebLinkAbout867687STATE OF UTAH
ss.
COUNTY OF UTAH
RECEIVED
AFFIDAVIT TO SEVER JOINT TENANCY ;N(',( r r
867687
00 AUG 22
1 5 0
KE MME R, Vd OM1NG
BOOK PR PAGE
I, Byron M. Thurman, being first duly sworn, depose and say that:
1. I am the Byron M. Thurman that appears as grantee on a Warranty Deed,
dated December 5, 1964, and filed as Entry No. 386829 in the records of the Recorder for
Lincoln County, State of Wyoming, wherein I and my spouse, Gayle. Thurman, took title to the
following described property in the County of Lincoln, State of Wyoming, as joint tenants with
rights of survivorship:
Parcel 1:
Southeast Quarter of the Northwest Quarter (SE1 /4NW1 /4) of Section One (1),
Township Thirty -two (32) North, Range One Hundred Nineteen (119) West of the
6` Principal Meridian, in Wyoming, together with all water rights thereunto
belonging.
Parcel 2
Southwest Quarter of the Southwest Quarter (SW1 /4SW1 /4) of Section Two (2)
in Township Thirty -two (32) North of Range One Hundred Nineteen (119) West
of the 6 Principal Meridian, in Wyoming, containing 40 acres of land be there
more or less.
Parcel 3:
Beginning at the SE Corner of Lot 2 (NW1 /4NE1 /4) of Section 1, T. 32 N., R.
119 W. of the 6th P.M., Wyoming, thence 186 feet North, thence 200 feet West,
thence North 170 feet, thence East 200 feet, thence North 346 feet, thence West
479.5 feet, thence South 70 feet, thence West 51 rods, thence South 39 rods,
thence East 80 rods to the point of beginning.
2. My spouse, Gayle H. Thurman, died on January 4, 1997, and I hereby
certify that she is the deceased listed on the Certificate of Death, attached hereto as Exhibit A.
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'000Z `lsany Jo /CEP ,S i sN1 MEG
(was)
I NAME OF DECEDENT -FIRST (GIVEN)
Gayle
2. MIDDLE
Hillyard
3. LAST (FAMILY)
Thurman
4. DATE OF BIRTH MM/DD/CC YY
11/10/1927
5. AGE YRS. IF UNDER 1 YEAR
IF UNDER 24 HOURS
6. SEX
7. DATE OF DEATH M M D D /CCYY
01/04/1997
8. HOUR
0242
MONTHS I DAYS
69 1
HOURS I MINUTES
1
F
9. STATE OF BIRTH
WY
10. SOCIAL SECURITY NO.
527 -26 -9684
11. MILITARY SERVICE
19 To 19_ NONE
12. MARITAL STATUS
Married
13. EDUCATION -YEARS COMPLETE,
14
14. RACE
1S. HISPANIC SPECIFY
YES
X
No
16. USUAL. EMPLOYER
Self- Employed
4 w
17 M L:_
'1 e n
18. KIND OF BUSINESS
Own Home
19. YEARS IN OCCUPATION
50
RESIDENCE BIER OR LOCATION
t f sF
ob West
k
H h1a Ail X'
22. COUNTY
Utah
23. ZIP CODE
84003
24. YRS IN COUNTY
10
25. STATE OR FOREIGN COUNT;
UT
26. N RE NSHIP /'r(
oh I. Thu usband
27. MAILING ADDRESS (STREET AND NUMBER OR RURAL ROUTE NUMBER, CITY OR TOWN, STATE, 2I1
11163 North 5550 West, Highland, UT 84003
r NAME OF SURVIVING SPOUSE -FIROT
Syron
Sy
29. MIDDLE
McCombs
30. LAST (MAIDEN NAME)
Thurman
31. N Ali 6F FATHI);R =F1'RT
I Leslie
32. MID6LE
33. LAST
Hillyard
34. BIRTH STA1
UT
35. NAME OF MOTHER -FIRST
Ada
36. MIDDLE
Elizabeth
37. LAST (MAIDEN)
Wood
38. BIRTH STAT
WY
39. DATE M M D D C C Y Y
01/08/1997
40. PLACE OF FINAL DISPOSITION
American Fork Cemetery, American Fork, UT 84003
41. TYPE OF DISPOSITION(S)
TR /BU
42. SIGNATURE OF EMBALMER f
43. LICENSE NO.
7427
44. NAME OF FUNERAL DIRECTOR
Eternal Hills Mortuary
45. LICENSE NO.
FD -234
46. SIGNAT d.Jy •CAL RED
k
47. DATE MM /DD /CCYY
01/08/1997
101. PLACE OF DEATH
Own Home
102. IF HOSPITAL, SPECIFY ONE:
IP ER /OP DOA
103. FACILITY OTHER THAN HOSPITAL:
CONY.
HOSF. x RES. OTHER
104. COUNTY
San Diego
1 O5. STREET ADDRESS- STREET AND NUMBER OR LOCATION
3266 Isabella
1 Q6. CITY
Oceanside
107. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE FOR A. B. C. AND D)
IMMEDIATE
CAUSE (A) Probable ASHD
TIME INTERVAL
BETWEEN ONSET
AND DEATH
108. DEATH REPORTED TO CORONER
X
YES NO
REFERRAL NUMBER
01 -073
Unknown
109.
BIOPSY
PERFORMED
YES
R NO
DUE TO (B)
DUE TO (C)
110.
AUTOPSY PERFORMED
YES X NO
DUE TO (D)
111.
USED
IN DETERMINING
YES X
CAUSE
NO
112. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RELATED TO CAUSE GIVEN IN 107
None
113. WAS OPERATION PERFORMED POR ANY CONDITION IN ITEM 107 OR 1127 IF YES. LIST TYPE OF OPERATION AND DATE.
NO
114. I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE
DEATH OCCURRED AT THE HOUR. DATE AND
PLACE STATED FROM THE CAUSES STATED.
I
DECEDENT ATTENDED SINCE DECEDENT LAST SEHN ALIVE
MM /OD /CCYY I MM /DD /CCYY
08/22/1996 1 08/22/1996
115. SI E A TIT OF CERTIFIER
01.
116. LICENSE NO.
G072347
117. DATE MM/PD/CC Y Y
01/07/1997
118 TT PH IAN'S NAME. MAILING ADDRESS ZIP
Steven S. n•- M.D., 145 Thunder Drive, Vista, CA 92083
1 CERTIFY THAT IN MY OPINION DEATH OCCURRED
AT THE HOUR, DATE AND PLACE STATED PROM
THE CAUSES STATED.
119. MANNER OF DEATH
NATURAL SUICIDE C HOMICIDE
COULD NOT
ACCIDENT NVE DETERMINED E
120. INJURY AT WORK
YES NO
121. INJURY DATE M M 0 0 C C Y
122. HOUR
123. PLACE OF INJURY
124. DESCRIBE HOW INJURY OCCURRED (EVENTS WHICH RESULTED IN INJURY)
125. LOCATION (STREET AND NUMBER OR LOCATION AND CITY AND ZIP CODE)
126. SIGNATURE OF CORONER OR DEPUTY CORONER
127. DATE MM /DD /CCYY
128. TYPED NAME, TITLE OF CORONER OR DEPUTY CORONER
A
B
C
D
E
F
G
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STATE FILE NUMBER
Exhibit "A"
CERTIFICATE OF DEATH
STATE OF CALIFORNIA
USE SLACK INK ONLY /NO ERASURES. WHITEOUTS OR ALTERATIONS
VS -11 (REV. 7/93)
572
LOCAL REGISTRATION NUMBER