HomeMy WebLinkAbout867329STATE OF WYOMING
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COUNTY OF
Cif 3, c;40 D
Dater
AFFIDAVIT OF SURVIVORSHIP
REAL PROPERTY
867329
BOOI4449 PR PAGE_ 5 .5_21
That said property is 1 at 42aeb
in the City of
RECEIVED.
FCC ^I j� r n !,l/ C;
OP AUG -3 AM
JEA NE f uNEli
KEMMERER. WYOMING
COMES NOW
deposes and says:
1. That this affidavit is executed pursuant to Wyoming statutes Section
2 -9 -102 (1977);
2. That affiant is the surviving widow(er) o
having been duly sworn and
3. That attached hereto is a certified copy of the death certificate
for is 09 A. 4 J
who died on
2 197c7 atA c�,/�' J City of
e,4„ State of
4. That the decedent names in the attached certified death certificate
(Exhibit A) is the same person named as one of the parties in the attached deed
(Exhibit B) dated 7� c' 19,a executed by
and to
as
recorded 19
in Book .2J at page 3 9 of the official records in
County, State of Wyoming;
5. That the legal description of the property is O 41. -).5 e 6
..s_e;.:
County, State of Wyoming;
7. That this affidavit is made in order to reflect that affiant is now and
has been at all times since the death of
the undivided owner of the above described property.
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LOCAL FILE NUMBER
T 1 OECEDENT•NAME FIRST
PERMANENT EIYVYN
eat 4. SOCIAL SECURITY NUMBER
FOR
uisTRuctloNS 518•324323
SEE
HANDBOOK
VR 2 -89
8/97 15M
7a PLACE OFDEATH(CNeA'enfy:.ana)
70. FACEITY NAME IN not Mtltutkn, ,M epeet and
200 Fifth Street
ESTA OF BIRTH (5 not In USA.. ran.
Idaho
iti F'(:SII IOt,
if RIIFIf H
<ii Iri I H
fit
24; NAME AM:J ADCRESS OF
0 12081144 OER)OWpadent ❑DOA
Mr tt
(5—
220 OWE
220. NAMEOF
U»). ARI SD FCYICE8? 12 USUAL OCCIIHLTION'
Brand Inspector
13b. COUNTY 13e CITY. TOWN OR LOCATION
Lincoln Cokexi],]te
MP. Yi P 417
81 °4F tittal,Ropkvelatiq
l2, Colcaville ,iyoming ''831111
DVat 20b 1Ata,'0.y. *7 20a CEMETERY OR CREAMATORV
Oa 2 3.999 Coker .11e Ceniet
Note Company
STATE OF WYOMING
DEPARTMENT OF HEALTH
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
Marna Home (sm. �OYw:lSPMd7Y)
Y T0. O1TY OF DEATH
l,"Okevi�1
lb.'NAME OF FACILITY
Matthew IHor1
LAST
SPARKS
Sb. UNDER 1 YEAR
DUE NJ (CR AS A CONSEQUENCE OFT
WE TO (05 As 1 CdNBEOLENCE OF):
DUE TO (OR AS A CONSEQUENCE OF):
18. Ma 7HETYS NAME FM
yrt1b Elissabeth
tab: RELATION
VI to
3 DATE OF DEATH (Ma. Oay, NJ
September 28, 1999
d. DATE OF BIRTH (Ma.' Op, WJ
Eebrusicy 25, 1922
STATE FILE NUMBER
7d. COUNTY OF DEATH
Lincoln
301. LOCATION (IE,M end Newest as Rung Roue* Number
OR TOWN STATE
Wyoming
'Idaho 83254
Zia HOUR OF DEATH
23e. PRONOUNCED DEAD (Nev)
27. AUTOPSY (Specify 2B. 111 CABE REFERRED TO CORONER
yr, ar no. ltp•cay yea. Of a0)
No AO
30d. DEBCR!BE HOW INJURY OCCURRED
ANY OR
OIDS THIS CERTIFICATE'
098425
This is a true and exact reproduction of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.
DATE ISSUED; O�''
Lucinda McCaffrey
Deputy State Registrar
This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar:.
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