HomeMy WebLinkAbout973729STATE OF WYOMING
SS
COUNTY OF LINCOLN
AFFIDAVIT OF SURVIVORSHIP
Dian Jackson, first duly sworn, upon oath, deposes and says:
1. My given name is Diane Louise Evans. I am now known as Dian L.
Jackson and also known as Diane L. Jackson.
2. Dian Jackson is the widow of George S. Jackson and has knowledge of
and is competent to testify concerning the facts as stated below.
3. Dian Jackson and George S. Jackson were married to each other on June
21, 1987 in Los Angeles County, California.
4. Dian Jackson and George S. Jackson they lived together as husband and
wife in Lincoln County, Wyoming continuously since 1993 and until the death of George
S. Jackson.
5. Dian Jackson and George S. Jackson owned, as tenants by the entireties,
the following real property in Lincoln County, Wyoming:
a. Lot No. 25, Cedar Creek Ranches Subdivision, as indicated on the
plat thereof in the Lincoln County Clerk's Office, Kemmerer, Wyoming;
and
b. Lot No. 28, Cedar Creek Ranches Subdivision, as indicated on the
plat thereof in the Lincoln County Clerk's Office, Kemmerer, Wyoming.
6. On August 11, 2013, George S. Jackson died in Lincoln County,
Wyoming. Attached is a Certified Copy of his official Death Certificate certified to by
the State of Wyoming, Department of Health.
0435'
RECEIVED 10/16/2013 at 11:10 AM
RECEIVING 973729
BOOK: 822 PAGE: 435
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
7. By reason of the death of George S. Jackson on August 11, 2013, Dian
Jackson became the sole owner of the above described property.
8. This transfer is completed upon the exchange of sufficient consideration,
the receipt of which is hereby acknowledged.
9. I hereby waive all rights pursuant to the homestead laws of the state of
Wyoming.
DATED: this 47 day of September, 2013.
Subscribed and sworn to before me by Dian Jackson this 91 day of
September, 2013.
Witness my hand and official seal.
AZARI PONCE NOTARY PUBLIC
COUNTY OF STATE G'
SEAL LINCOLN WYOMIN. NOT RY PUBLIC
i lP
MY COMMISSION EXPIRES 111211201
My commission expires: 11 j I201 L
2
1 Qr
Dian Jackso
rt c am.: to uc
CERTIFICATION OF VITAL RECORD
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
James McBride
Deputy State Registrar
fifir
Decedent:
Name: George Stanley Jackson
Gender: Male
Date of Birth: November 03, 1931,
Date and Place of Death:
Date of Death: August 11, 2013.
City of Death: Thayne
Location: 32 Hoback Dr.
Additional Decedent Information:
Place of Birth: Perryton, Texas
Residence: Thayne, Wyoming
Marital Status: Married Diane Louise Evans
Armed Forces: No
Name of Father: Charles Benoni Jackson
Name of Mother: Fanny Drake
Informant: Diane Louise Jacison
Disposition:
Method of Disposition: Cremation
Place of Disposition: Schwab Mortuary Crematory, Afton, Wyoming
Funeral Home or Facility:
FacilitS': Schwab Mortuary, Afton, Wyoming
Cause of Death:
The immediate cause. is listed on the first line followed by any underlying causes.
(a) Lung CA
(b) COPD
Other Significant.
Conditions:
Manner of Qeath:
Certifier:
Type:
Name:
Address:
Date Filed:
71972/
Natural Death
August 26, 2013
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming.
DATE ISSUED: .Tuesday, August 27, 2013
This copy is not valid unless prepared on paper with an engraved. border.
State File Number:
Social Security Number:
Age at the Time of Death:
County of Death:
Relationship:
Time of Death:
Physician
Michael Pieper, D.O.
110 Hospital Lane, PO Box 579, Afton, Wyoming, 83110
2013- 002582
81 years
Lincoln
Wife
Interval.
03:00 (Actual)