HomeMy WebLinkAbout974320RECORDING REQUESTED BY
WHEN RECORDED RETURN TO:
PAUL G. JENSEN
2049 North 1210 West
Pleasant Grove, Utah 84062
Tax Number: GEO -Pin Number: 32193640009300
Address: Lot 43, Afton Air Park, Afton, WY 83110
1, PAUL JENSEN, being duly sworn, say
Dated this 15 day of August, 2013.
RECEIVED 11/27/2013 at 11:02 AM
RECEIVING 974320
BOOK: 824 PAGE: 605
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT of DEATH of TENANT by the ENTIRETIES
0005
I am 18 years of age or over. The decedent described in the attached certified copy of Certificate
of Death is the same person as SUE JENSEN, who is named as one of the parties in the deed
dated April 27, 2006, executed by BARRMORE, LLC, a Wyoming Limited Liability Company
conveying the subject property to PAUL JENSEN and SUE JENSEN, husband and wife as
tenants by the entireties, recorded on April 27, 2006 as Entry 917821, in the Official Records of
Lincoln County, Kemmerer, Wyoming in Book 618 at page 21, described as follows:
Lot 43 of Afton Airpark Addition to the Town of Afton, Lincoln County, Wyoming,
according to that plat files August 1, 2005 in the office of Lincoln County Clerk as Plat
167 -C
STATE OF UTAH
COUNTY OF UTAH
ss.
NOTARY ACKNOWLEDGEMENT
06
cu., I, LAUREL C. BACKMAN, Notary Public in and for the State of Utah, do hereby certify that on this
/S day of August, 2013, personally appeared before me PAUL JENSEN, to me known to be the individual
described in and who executed the within AFFIDAVIT OF DEATH OF TENANT BY THE ENTIRETIES and
acknowledged that he did so as his free and voluntary acts and did for the uses and purposes herein mentioned.
r Yisi
Signed and sworn to before me this day of August, 2013.
L B RIDDLE
NOTARY PUBUC•STAIE OF UTNM
COMMISSIONS 667959
COMM. EXP. 06.23.2017
N ary .b n and for the State of Utah, residing at
Pleasant Grove, Utah.
My comm'n expires: 6 -23 -2017.
Frit
DECEDENT INFORMATION
Date of Death: December 1. 2008
City of Death:
Age:
Place of Birth:.
Armed Services:
Spouse's Name:
Industry/Business:
Residence:
Mother's Name:
Facility or Address:
CERTIFICATION OF VITAL RECORD
n AVNW A VAVAWIMWAW VM
Salt Lake City
50
Long Beach, California
No
Paul Gail Jensen
Law
Pleasant Grove, Utah
Carol Inga Loe
`Huntsman Cancer Hospital
CERTIFICATE OF DEATH
State File Number: 2008013540
Sue Ann Jensen
Time of Death:
County of Death:
Date of Birth:
Sex:
Marital Status:
Usual Occupation:
Education:
Father's Name:
Facility Type:
INFORMANT INFORMATION
Name: z Victoria Lynn Crowe Relationship: Sister
Mailing Address: P.O. Box 582 Santaquin, Utah 84655
DISPOSITION INFORMATION
Method of Disposition: Cremation
Place of Disposition: Utah Funeral Directors Cremation Center, South Jordan, Utah
Date of Disposition: December 3, 2008
FUNERAL HOME INFORMATION
Funeral Home: Olpin Mortuary Pleasant Grove
Address: 494 South 300 East, Pleasant Grove, Utah 84062
Funeral Director: Paul 'D Olpin
MEDICAL CERTIFICATION
Physician: Hope l City, R
Certifying Ph sician: Martha J Glenn MD, 2000 Circle of Ho a Suite 2100, ake Cit ,Utah 112 4
'CAUSE OF DEATH
Acute myelogenous leukemia [Onset: 7 Months]
Chronic myelogenous leukemia
Tobacco Use: Non -user
Medical Examiner Contacted: No Autopsy Performed: No Manner of Death: Natural
14:24
Salt Lake
August -16, 1958
Female
Married
Paralegal
Associate Degree
Donald Eaton Suthlerland
Hospital :Inpatient
Healt�)1Se
Date Issued: March 5, 2009
d
/t iILL
8 9 6 �/i,
g/ 1 A.,,AA AA
Barry E. Nangle, State Registrar
Office of Vital Statistics
1.�1 11/01 MI UM V I 1 ip
AMENDMENT HISTORY
02/09/2009 Decedent Date of Birth from. 08/17 /1958 to 0811611958
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 the Utah State Seal, over the words "State of Utah This
document displays the date, seal and signature of the State Registrar and the County /District Health Officer.
II 11 1 1 1111 11 11111 1 11
Gary t Ellwards
Director/Health Officer
County /District Health Department
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