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Parcel 1:
Parcel 1:
Affidavit of Trustee
I, Patty Jo Douglas, being of lawful age and duly sworn according to law, upon my oath, depose and
That under the date May 22, 2006, Jack Dee Douglas, a /k /a Jack D. Douglas, and Patty Jo Douglas,
husband and wife, by deed of that date, which deed was duly filed of record in the Office of the Lincoln
County Clerk, on May 24, 2006, in Book 621 on Page 68, conveyed to JACK D. DOUGLAS and PATTY JO
DOUGLAS, as Trustees of the JACK D. DOUGLAS AND PATTY JO DOUGLAS TRUST dated May 22, 2006,
the following described property situate in Lincoln County, Wyoming, to -wit:
The Lot Numbered Six (6) of the Block Numbered Four (4) of the Original Townsite of Kemmerer, Lincoln
County, Wyoming
Lot 5 of Block 4 of the Original Town of Kemmerer, Lincoln County, Wyoming as described on the official
plat thereof
That by reason of said conveyance aforesaid, JACK D. DOUGLAS and PATTY JO DOUGLAS, as
Trustees of the JACK D. DOUGLAS AND PATTY JO DOUGLAS TRUST dated May 22, 2006, became the
owners of the above described land, and title thereto vested continuously in said trustees from the date of
conveyance described in said deed to the date of death of Jack Dee Douglas, on the 11th day of December,
206. That by reason of and upon the death of Jack Dee Douglas, also known as Jack D. Douglas, and
pursuant to ARTICLE VI. of the Trust Agreement, title to the above described real property vested in Patty
Jo Douglas, as sole trustee.
Affiant avers and certifies that Jack Dee Douglas, also known as Jack D. Douglas, is the identical
party named as trustee in the aforementioned deed, whose death terminated his interest, title and estate in
said real property; and Affiant attaches hereto and makes a part of this affidavit, the Official Certificate of
Death of said decedent, duly certified by the public authority in which said death certificate is a matter of
record.
h
Dated thisr'� day of
State of W VV`\S"
County of
)ss.
Subscribed and sworn to before me, a notary public in and for said County and State, by Patty Jo
Douglas, this <ac`tti day of 2013.
WITNESS my hand and official seal.
My Commission Expires: /0 /7
RECEIVED 11/1/2013 at 3:06 PM
RECEIVING 973983
BOOK: 823 PAGE: 475
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
0475
Notary Public
TAMMY LAFAVE NOTARY PUBLIC
COUNTY or T STATE OF
LINCOLN WYOMING
ono DECEMBER 3, 2014
TAL RECORD S
ViVvW
Barry E. Nangle, State Registrar
Office of Vital Statistics
CERTIFICATE OF DEATH
State File Number: 2006015096
Jack Dee Douglas
Time of Death:
County of Death:
Age:
Place of Birth:
Armed Services:
Spouse's Name:
Industry/Business:
D Residence:
Mother's Name:
Facility or Address:
14:49
Salt Lake
59
Rock Springs, Wyoming
No
Patty Jo Slovernick
P M Chevron Coal Mine
Kemmerer, Wyoming
Jean Marie Marocki
University of Utah Hospital
Manner of Death: Accident
DECEDENT INFORMATIO
Date of Death:
City of Death:;
Social Security Number:
Date of Birth:
Sex:
Marital Status:
Usual Occupation:
Education:
Father's' Name:
Place of Death Type:.
INFORMANT' INFORMATION
Name: Patty Jo Douglas Relationship:
Mailing Address: 420 Pearl Street, Kemmerer, Wyoming 83101
DISPOSITION INFORMATION
Method of Disposition: Cremation Date of Disposition: December 14, 2006
Place of Disposition: Utah Funeral Directors Cremation Center, South Jordan, Utah
FUNERAL HOME INFORMATION
Funeral Home: Jenkins -Soffe South Valley
Address: 1007 West South Jordan Parkway, South, Jordan, Utah. 84095
Funeral Director: Kurt L Spffe
MEDICAL CERTIFICATION
Certifying Physician: Meic Schmidt MD, 50 North Medical Drive, Salt Lake City, Utah 84132
CAUSE DEATH
Closed head -injury
Fall
Tobacco`' Use: Did not Contribute
Medical Examiner Contacted: Yes Autopsy Performed: No
INJURY INFORMATION
Date of Injury:
Injury at Work:
Location of Injury:
I- ow,Injury Occurred:-
Motor Vehicle Accident:
N'
December 11, 2006
Salt Lake City''
March 22, 1947
Male
Married
Pit Supervisor
High School or GE
Douglas Jack
Hospital Inpatient
December 4, 2006 Time of Injury:
No Place of Injury:
11 Chicago St., Diamondville, Wyoming
Ladder slid out from under him and he struck head on
Concrete garage floor
No
I1
*061231984
DATE ISSUED: January 2, 2007
AMENDMENT` HISTORY
12/28/2006 Industry from Oil Gas Recovery to P M Chevron Coal Mine
12/28/2006 Injury Street from 420 Pearl Street to 11 Chicago St.
1.2/28/2006 Injury City from Kemmerer to Diamondville
12/28/2006 Injury Description from Fell off ladder whhile hanging outside liightss and struck he to La ddler slid o
T his is an exec' reproauc on of TOO docune t regis ere n e ate ice o i a
Security features of this official document include: Intaglio Border, V R images in top cycloids,
ultra violet fibers and hologram image of a hawk over the wprd valid.This document displays the
date, seal and signature of the State Registrar and the County /District Health Officer.
Updated Utah State Seal rep aces hawk overyalid for authenticity.
Gary4 Edwards
Director /Health Officer
County /District Health Department
kr
DATE ISSUED: January 2, 2007
This is an exact reproduction of the document registered in the State Office of Vital Statistics.
Security features of this official document include: Intaglio Border, V R images in top cycloids,
ultra violet fibers and hologram image of a hawk over the word valid.This document d splays e;
date, seal and signature of the State Registrar and the County /District Health Officer.
Updated Utah State Seal replaces hawk over valid for authenticity.
Gar. Edwards
Director /Health. Officer
County /District Health Department
Jack Dee Douglas
AMENDMENT HISTORY (Continued)
12/28/2006 Injury Description from (blank) to Concrete garage floor
01/02/2007 Injury Place; from Decedent's Residence to Aunt's Residence
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0 41$ 11 .6" Office of Vital Statistics
CERTIFICATION OF VITAL RECORD
0 �1_ Barry E. Nangle, State Registrar
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