HomeMy WebLinkAbout867702State of Wyoming
nn County of Lincoln
BOOK 0 PR PAGE 5 3 8
AFFIDAVIT OF SURVIVORSHIP
I, Grant Gardner, being of lawful age and duly sworn
according to law, upon my oath, depose and state
That under the date of January 16, 1973, for valuable
consideration, Bruce LaVere Gardner and Jennie Gardner,
husband and wife, by deed of that date, which deed was
duly filed of record in the Office of the Lincoln County
Clerk, on January 30, 1976, in Book 123 of Photostatic
Records on Page 206, conveyed to Grant Gardner and Lorain
Gardner, husband and wife, as joint tenants and not as
tenants in common with full rights of survivorship, the
following described property, to -wit:
Lot Two (2) in Block Five (5) Grover Townsite
Survey, Lincoln County, Wyoming
That by reason of said conveyance aforesaid, the said
Grant Gardner and Lorain Gardner, husband and wife, became
the owners of the above described land, and title thereto
vested in them continuously from the date of conveyance
described in said deed to the date of death of Lorain
Gardner, also known as Millie Lorraine Henderson Gardner,
on the 14th day of April, 1989. That by reason of and
upon the death of Lorain Gardner, title to the above
described real property vested absolutely in Affiant, Grant
Gardner, as surviving spouse.
Affiant avers and certifies that Lorain Gardner, also
known as Millie Lorraine Henderson Gardner, 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.
DATED this 9p-- day of
Subscribed and sworn to before me and in my presence
by Grant Gardner, this a q day of
2000.
WITNESS my hand and official
WANDA N. NEWMAN NOTARY 45i'37:17 °'t
COUNTY OF �r r
LINCOLN STATE OF
WYOMING
My Commission Expires 6
My Commission Expires:
)8O/702
G ant Gar ner
seal.
AA) (4i
RECEIVED
00 AUG 22
2000.
Notary Public
4'
DEPARTMENT OF,,HEALTH
Ft•.T
11 CA DEATI((ITEM
d riedcal Drivv,8•
,($freel.er'ijPaf rou(0 teohbet o(y or awn, county and stale)
�raa,�ES�ra'�
AR
N
4f BIRy )IM
Yr1 y:a�laaro;
*tang
TATS 0f UTAH DEPARTMENT OF HEALTH 1 A 3
RT1FICATE OF DEATH 1 r -i
ne' JRettdersor GARDNER
If UNbER l YEAR IF UNDER 21 HOURS 6
001116",1 Days.
,e011(0 h90k Only. 10154)
10 009)119 .Hpme t..3 Residence Other
COUNTY OF DEATH
It
st Street
LAST
Hours r Minutes
120. DECEDENT'S USUAL OCCUPATION (Give kind of work done
during most of working 11e. Do NOT use retired)
Secretary
130 CITY, TOWN, OR COMMUNITY
Salt Lake City
WO ENT OF, HIS?ANIC Yes No
Iran L)'Guban I� Puert0 Rican El Other (Speciy
1 n der s oe
AbpA�5�S OF INFpRMANT;
usband)`/ 1192 North 1500 West Street SLC.
ATE OF DISPOSITION 211: PLACE :OF DISPOSITION (Name of cemetery 21c. LOCATION
crematory, or other place)
,1989 Afton City Cemetery
A (Na
N$ tH9T O ED� E'D6ATy. DO NOT THE i DE MO OF DYING, SUCH AS CARDIAC Approximate Interval
1'ISTONLP DAUSE CSN EACH LINE. I Between Onset And
Death
h. U-4o %.&ce L- YU6 N_3V._(�'l 1 trk 71c1
19Rl+s A CONSEOueNCEoF).
t 3LS. o\ vi C• 1 t'n o•
s pFJ:
WAS'a Cd6SEOU €NOEOFI:
Ip
afli b4t rill'.';
DAT' OF,INJURY
>f f.. Dsy 10860•.
32. IN YOUR OPINION, TOBACCO USE BY THE DECEDENT
Probably Centrlbuled to the cause of death
Was.. the underlying cause of death
9 r. �DI not 4 niribute 10 the cause of death
J 9 unknown In relation to the cause of death
35b. TIME OF INJURY
(24 Hour Clock)
STATE FILE NUMBER
2. SEX 3a- DATE OF DEATH (Mo. Day, Yr)
Female April 14, 1909
6. BIRTHPLACE (City a mate a Poop. Cameyl
Afton, Wyoming
6b, NAME OF HOSPITAL. NURSING HOME OR OTHER FACILITY (II outside a facility,
give street address of localion)
University Hospital
9. SURVIVING SPOUSE el wile, give maiden name)
Grant 0. Gardner
13c. COUNTY
Salt Lake
15. RACE Black, While, Am. Indian
(Tribe maybe entered). Japanese.
em. (Specify)
Caucasian
18. MAIDEN NAME OF MOTHER (First. Middle. Last)
Millie Henderson
35c. INJURY AT WORK?
NON -USER
John E. Brockert
DIRECTOR OF VITAL STATISTICS
139 00
121. KIND OF BUSINESS OR INDUSTRY
Secretarial
Banking
16. EDUCATION (Specify only highest grads
completed) Elementary or Secondary
(0- 12)- College (13 -16 or 17 .1
Lincoln County, Wyoming
ddress and license number)
IN MORTUARY
00 East South Temple Street
jlt I, ,ke City, UTAH
84111 -1274
s s and manner as stated
}Q SIGNED (MO.. Day. Yr.)
s
ail 1L' 1989
3310 WAS AN
AUTOPSY
PERFORMED?
Yes No
the Certificate on file in this office. This certified copy is issued
ah' Code Annotated, 1953 As Amended.
b. TIME OF DEATH (2x hr. dock)
0900
7. SOCIAL SECURITY NUMBER
528 -48 -4918
14
13d. STATE
Utah
30. DATE FILED (Month. Day. Year)
April 18, 1989
33b WERE AUTOPSY
FINDINGS AVAILABLE
PRIOR TO COMPLETION
OF CAUSE OF DEATH?
L J Yes No
35d. PLACE OF INJURY- AIhome. term. street. laClory,
office. building, etc. (Specify)
359. mo vehicle c
acident p
secify If decedent was
d riv er, passenger or pedestrian.
OW,)NJURY OCCURRED (enter sequence of events which resulted in injury. NATURE OF INJURY SHOULD BE ENTERED IN ITEM 31)
599
WARNING: IT LS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES.
Y ANY ALTERATION OR ER SURE vOIDS THIS CERTIFICATION