HomeMy WebLinkAbout865800THE STATE OF WYOMING
COUNTY OF LINCOLN
Bowers Law Office, P.C.
P.O. Box 1550
Afton, Wyoming 83110
307 -885 -0640
865800
AFFIDAVIT OF SURVIVORSHIP
STEPHEN L. OLSEN, being first duly sworn upon his oath, deposes and states
as follows:
1. On or about the 19 day of September,1996, my wife, Laura Lee H. Olsen,
died as is evidenced by the official certificate of death attached hereto and incorporated
herein by this reference.
2. At the time of her death she jointly owned an interest in certain real property
with me, said real property being located in the County of Lincoln, State of Wyoming,
and more particularly described as follows:
A portion of the SW'/NE /4. Section 35, T33 N, R 119 W, 6 P.M., being
more particularly described as follows:
Beginning at the Northeast Corner of said SW' /4NE of said Section 35,
and running Westerly along the Northerly line of said SW1/4, 417.42 feet;
thence South, parallel with the Easterly line of last said SW 208.71 feet;
thence East parallel with the Northerly line of said SW' /4, 417.42 feet
thence North along said Easterly line of said SW /4, a distance of 208.71
feet to the point of beginning.
Subject to all easements, reservations and rights of way of sight or record.
Also subject to two mortgages to the Star Valley State Bank, securing
notes in the amount of $10,119.00 and $35,000.00 respectively, recorded
in Book 176 of P.R., Page 241 and in Book 199 of P.R., Page 105 Lincoln
County Clerk, which mortgages grantor agrees to discharge and pay in
full.
3. Said real property interest was originally conveyed to Stephen L. Olsen and
Laura Lee H. Olsen, husband and wife, as tenants by the entireties, with right of
survivorship, by a Warranty Deed dated August 26, 1983, and recorded August 31,
1983, in the Office of the Lincoln County Clerk and Ex- Officio Register of Deeds in
Book 176 of P.R., Page 241 and Book 199 of P.R., Page 105.
1
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CERTIF ICAT ION OF VITAL RECORD
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!i ANY ALTERATION OR E
PARENTS
IN fol;L1,l NT
�IS PO S T ION
CL RTIE ILR
of [)L 0)0
29. MANNER DEATH
turat OPendlno OI
Accident
30a. DATE OF INJURY
(AWOL Day, Year)
306. TIME OF
INJURY
300. INJURY AT WORK?
Moody yes anal
27. AUTOPSY (Spool&
JeL no,
26. WA8 CASE REFERRED 10 CORONER
(S po lyJse
of ne)
08b
TYPE
OR PRIt4T
PERMANENT
FOR
INSTRUCTIONS
SEE
HANDBOOK
VR 2 -89
4/94 15M
SOO
LOCAL 815 NUMBER
1. DECEDENT -NAME FIRST
LAURA LEE
4. SOCIAL SECURITY NUMBER
528 -56 -8976
7s. PLACE OF DEATH (Check only one)
Inp.tl.ni JER /Oupatient CDOA I B
7b. FACIUTY NAME III gfse RAW ad nunber)
STAR VALLEY HOSPITAL,
8. STALE OF BIRTH (M not h USA., nary.
WYOMING
11. WAS DECEDENT EVER IN U.S, ARMED FORCES?
(Specify yes or no)
13a. RESIDENCE STATE
WYOMING
13.. INSIDE CITY LIMITS?
(Speclly me or 00),
NO
8
17. FATHER'S NAME
LEHI
Ma. INFORMANT-NAME (Type or Mint)
STEPHEN OLSEN
r 20a. Burial, Cremation, Removal
ken Stale, Other Specify)
MIT M. OTHER SON
STATE OF WYOMING
7)
13b..00097Y
LINCOLN
MIDDLE
HOKANSON
55. AGE -oat 841645.
(Yeas)
190. MAMJNG ADDRESS STREET OR R.F.D. NUMBER
51 TOMS CANYON
Lax
HOKANSON
Months
tic CITY; TOWN OR LOCATI3tl
AUBURN
44 WAS DECEDENT OF HISPANIC ORIGIN?
(SpadaY w a.. a 44444tH.)
gNr4( R Etc.)
20h. DATE (6b, Dajy- 1,) 2005 CEMETERY OR CREMATORY NAME 20d. LOCATION CITY OR TOWN STATE
SEPTEMBER 23,96 HYDE PARK CEMETERY'', HYDE PARK. UTAH
or Pawn Acanp Nulnha, 216. NAME OF FACILITY Number 21c. ADDRESS OF FACILITY
SCHWAB MORTUARY .45 44 E. FOURTH AVE., AFTON
32a. To the bat Mated.
h fin
dlN. death onaurred sl ice e, data and 5)500 .0 do.
camels)
(8WrWUre and not..
220. DATE SIGNED (Ma Da y y, '(1 188)
22d. NAME NA PHYSIC
24. NAME AND ADDRESS OF CERTIFIER (PIIYSK2AN OR CORONER)(71p are Prka(
4.Val r 6'r l
2855 REGISTRAR A�
(Sbm0 1 P4r.
MIT 1. Enter the dim ama, INo4.a, or complications But nosed death. Do not enter the mode d dy1'., 5006.4 carded 28. a resplraNay Week shock, a (mut Name. UN only one muse on ern Ilha.
IMMEDIATE CAUSE (Final
diseaen or condition
resulting In dente) a
S.phrm00lly lal conditions.
II any, leading to Immediate
ma Enter UNDERLYING
CAUSE (Memo or Inlory
that Initiated events
romans b death) LAST
08544
DUE TO (OR AS A
DEPARTMENT OF HEALTH
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
'M
LAST
OLSEN
56. UNDER 1 YEAR
Dan
ro Home O R.eld.nee O Other (5.00)ly)
WHITE
IS. MOTHERS NAME
VIRGINIA
CITY OR TOWN BTAtE
AUBURN WYOMING
(UENGE 05):
This is a true and exact reproduction of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.
DATE ISSUED: 1
Howe
50. UNDER 1 DAY
15. RACE-American Indian,
2. SEX
EMALE
Minutes
70. CITY, TOWN OR LOCATION OF DEATH
AFTON
DUE 70 (OR AS A CONSEQUENCE OFI: J
191. RELATIONSHIP TO DECEDENT
HUSBAND
This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar.
STATE FILE NUMBER
3. DATE OF DEATH (MO., 0.44 N.)
SEPTEMBER 19, 1996
8. OATS OF BIRTH (Ma, Dry, WJ
OCTOBER 4, 1940
S. MARRIED. NEVER MARRIED, 4O. SURVIVING SPOUSE at 10444. oAe =Man roma)
WIDOWED, DIVORCED (SPed4y)
MARRIED STEPHEN OLSEN
12.. USUAL OCCUPATION (Ohs kind or wab dorm during ma el 144)0. KIND OF BUSINESS OR INDUSTRY
or working We. 2 ra/redl
TEACHER
EDUCATION
134. STREET AND NUMD'6H
51 TOMS CANYON ROAD
7d. COUNTY OF DEATH
LINCOLN
I S. DECEDENT'S EDUCATION (Sp:ft any Kohut grad. conpaad)
Elementary/Secondary (0 -12) College (1.4 or 51)
ZIP CODE
83111
4
MIL
235 On is bawl b ..ortlnatbn end /or bN.elgMlon. In my opinion death occurred
.t the lime, 4)0 end plate and dm Ns staled.
(S/0rrh 0 and 7111e) ,/i +ANi�/T1�1
a 23b. DATE BIONEO (Ma, Dry, Yr.)
S 2ad.. NOUNCED DEAD (Ma, Dry,. W.)
641/
25b, DATE RECEIVE" BY REGISTRAR (Ma, Day W.
5
SCRIBE HOW INJURY OCCURRED
Lucinda McCaffrey
Deputy State Registrar
Malden Surname
!ApproxlmaN
'keened
IOn.at and Dash.
432
4430. HOOR 6 F DEA7R
M
23e. PRONOUNCED DEAD (Nos)
/:ASP M
301. LOCATION (Sheet and Number or Mind Rao Number, City a Town, Sale)
ENT 696 k3K Et 4 2 PG 23 1
tOIDS THl ENT 710542 P c PG 923