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B3.00K448_PR PAGE .0 7 9 ..I NcoLP NI JN TY 01.1 .1
Affidavit Aff iQ Mle 00 JUN 30 Pd 1; 54
I, Betty J. Evans, being duly sworn on oath depose ilEa' ei,GI'' L
as follows: KEMMERER. WYOMING
1. That on February 6, 1995, Gordon W. Evans executed a Power
of. Attorney in favor of Betty J. Evans, said Power of Attorney
being recorded February 13, 1996, at Book 380PR, page 178.
2. That on September 20, 1997, Betty J. Evans executed a
Warranty Deed from Betty J. Evans and as Attorney in Fact for
Gordon Evans, to Betty J. Evans, a married woman as her sole
and separate property, said deed being recorded October 6, 1997,
at Book 402PR, page 606.
3. That the following described property was listed on the
aforementioned deed:
Lot Sixty (60) in Star Valley Ranch Plat One (1), as platted
and recorded in the official records of Lincoln County, Wyoming
4. That Gordon W. Evans, also known as Gordon Evans, died on
November 7, 1997, as evidenced by the Death Certificate attached
and made a part of this affidavit.
5. That Betty J. Evans owns the property as a single woman.
WITNESS my hand this 25th day of April 2000.
State of California
County of Kern
WITNESS my hand and official seal.
Bet y J. Evans
s s.
The foregoing instrument was acknowledged before me, a notary
public in and for said County and State, by Betty J. Evans this
25th day of April 2000.
My Commission Expires: January 12, 2004
51n11.
NAME Or DECIELNT -PIRST 1011401
Gordon
2. 91001E
Wayne
3. LAST IFANILYI
Evans, Sr..
GATE OF METH 14 M I 0 D C C Y Y
06/07/1916
S. AGE YES. IF UNDER 1 OAYS
24 MOW.
S. SEX
M
7, DATE OF DEATH M M I D D I C C Y Y
11/07/1997
6. HOUR I
1650
NORTH/
81
HOURS 1 MINUTES
1
DECEDENT
PERSONAL
9. •TATS OF BIRTH
WI
10, SOCIAL SECURITY No,
396 -01 -8596
11. MILITARY SERVICE
x YES NO
12. MARITAL STATUS
Married
19. EDUCATION -PEARS COMPLETED
13
14. RACE
White
16. HISPANIC SPECIFY
YES x NO
/S, uSUAL EMPLOYER
Smith Corona Office Equipment
IT. OCCUPATION
Sales
16. EURO OF BUSINESS
Office Equipment Sales
IN OCCUPATION
17
USUAL
RESIDENCE
20. RESIDENCE STREET AND NUMBER OR LOCATION
3100 Harrogate Lane
21. CITY
Bakersfield
22. COUNTY
Kern
23. 21P CODE
93309
24. YRS IN COUNTY
1
25. STATE OR FOREIGN COUNTRY
California
INFORMANT
26. HAM, IONSHIP
Betty Evans, wife
27. MAILING ADDRESS I O RUMEER OR RURAL ROUTE NoNSER. CITY OR TOWN, 2IPI
3100 Harrogate Lane, Bakersfield CA 93309
SPOUSE
AND
PARENT
28. NAME OF SURVIVING SPOUSE -IIR•T
Betty
29. 9)0011
Jean
4U. LAAT ,M .4.00 NAME/
Culver
31. NAM[ OI FATHER -FIRST
Frank
32. 91004.E
Abraham
33. LAST
Evans
34. S RTN .TA,E
PA
INFORMATION
33. NAME OF MOTHER -FIRST
Frances
]S. MIDDLE
37. LART IMAIDENI
Purdy
33. SMTH STATE
WI
DISPOSITION.
99. O M/ 0 0/ C C 1 Y
11/12 M /1997
40. PLACE OF /141•L DISPOSITION
:Palm Cemetery,•Las Vegas, Nevada
FUNERAL
DIRECTOR
AND
LOCAL
REGISTRAR
•1, TYPE Or DISPOSITIONIEI
CR /TR /BU
42. ,Yrl tU OF (MBA ER E
6699
C �.C� 1���-
4].' LICLIE.. LIE.. No.
Al. NAME of FUNERAL DIRECTOR
Peters Funeral Home
8. S NATURE OF LOCAL R[0IlT
LICENSE NO.
43. LIC[
FD1125 B. Jinadu, .M.D./
47, OAT[ M M 0 D
11/10/1997 A
PLACE
OF
DEATH
101. PLACE OP DEATH
S hafter Convalescent Hosp.
102. W HOSPITAL, SPECIFY ONE■
111 111
IP ER /OP DO
109. FACILITY OTHER TIM OS TAU
13 °NY- II
OSP. RE OTHER
104. COUNTY
Kern
105. STREET ADDRESS- STREET ANO NUMBER OR LOCATION
140 E.' Tulare Avenue
(00. CITY
Shafter
CAUSE
OF
DEATH
107. DEATH WAS CAUSED EY, /ENT[R ONLY ONE CAUSE PER LINE FOR A. 8, C, AND D1
IMMEDIATE
CAUSE
/V{ �a,�E/ ��l •i �F
DUE TO IBI 1 A1 r� d� ''j�/, L1h
!1 �C M
TIME 1
R ONSET
NO O[1TM
108. DEATH REPORTED TO CORONER
M1
III Y[6 No
n i ('n R q RER
(09
YES x NO
r /1�•(.
V 4 I[. �Y
DUE TO I
CI a 1u O, a fie
J IT] Yi J 1 J�1 EMCI /A frJ
(n,'
T`E
I IO.. AUTOPSY •E.01.1.
Y. NO
DUE TO IDI
111. 0040 I9 DETE4NIN NG CAUSE
YES No
112. OTHER SIG NW AUS T CAI DITTO f ONTRIBUTINB TO DEATH BUT NOT RELATED TO C E GIVEN IN 107
�L
lNE
113. WAS OPERATION 't' FORME0 FOR ANY CONDITION IN 1113 107 OR 1121 1F YES, LIST TYPE OF OPERATION AND DATE
PHYS1-
CI TIFI
CERTIFICA-
T1ON
114. I CERTIFY THAT TO THE BEST OF NY NNOWL-
[DO[ IMAM OCCURRED AT THE OUR, OAT[
PLACE STATE° 1RM TL SES
0[CEOENT AND 0 4 C ED SiNCf DEC C D U ET S[EN ALIVE
NM ∎DO.cC YY I Nw /DO
F/'7 J -4_97
11S. SIGNATURE AND L OF CERTIFIER
110. LICENSE
V
4 E.J
117. OATS M M T
v 0
E. MAILING
II9. PE TT .9� AN'f 21P
E
Jae Kim MD. 565 Kern Street, Shafter CA 93263
CORONER'S
USE
ONLY
I).--A
CEPTIYY THA t MY OPINION O[A1N
DST[ AHD PLA
STATED FROM THE CAUSES STATED.
119. MANNE TN
[.1 NATURAL O SUICIDE HOMICIDE
NoIHG uLO Noi 0f
O w MCNTE] INVESTIGATION DETERMINED
120. INJURY AT WO N
II YES D NO
121. INJURY DAlE N M O O I C C Y Y
122. HOUR
123. PLACE u
124. OE4CRISE HOW INJURY OCCURRED IEV[NTS WHICH RESULTED IN INJURY]
126. LOCATION 1SIRECT AND NUMBER OR LOCATION AND CITY, IIP/
120. 5IGNATUR0 OF 0000500 DR DEPUTY CORONER
O
I27. DATE M«/OD/CCYY
128. TYPED NAME. TITLE OF CORONER OR OEPUIY CORONER
REGISTRAR STATE
A
B
C
O
E
F
G
H
FAX AUTH. N
1099828
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CERTIFICATE OF DEATH
STATE OF CALIFORNIA ALTERATIONS
USE BLACK INK ONLY/ ERASURES, O ERAS W OUTS OR ALT[
CERTIFIED COPY OF VITAL RECORDS
Y\ STATE OF CALIFORNIA I ss DATE ISSUED
COUNTY OF KERN J 1
This is a true and exact reproduction of the document officially reg and p'Iac d
on file in the office of the VITAL RECORDS SECTION OF THE DEPARTMENT OF
PUBLIC HEALTH SERVICES.
'fhls copy is inn valid unless prepared on engraved border displaying seal and signature of registrar.
ANY AL ER ON 0
VOIDS HIS CERT ATE
CERTIFICATION OF VITAL RECORD
COUNTY of KERN
DEPARTMENT OF PUBLIC HEALTH 0 8 0
1700 FLOWER STREET, BAKERSFIELD, CALIFORNIA 93305 -4198
LOCAL REGISTRATION NUMBER
B.A. JINADU, MD, MPH
HEALTH OFFICER AND LOCAL REGISTRAR
OF BIRTHS AND DEATHS
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