HomeMy WebLinkAbout974739NTL -66596
When recorded mail to:
Neu Slat/nes
es
Comes now the undersigned Margo Starnes and being on oath first duly deposes and says:
1. That I am a citizen of the United States of legal age and capacity, and competent to make this affidavit.
2. That I was personally acquainted with the deceased, Eugene Ray Starnes aka Ray Starnes
3. That said deceased is one in the same person as Ray Starnes listed in that certain document as
recorded on 1/27/2011 at Entry No. 957810 in Book 761 at Page 435] in the office of the Lincoln County
recorder, State of WY.
4. That the purpose of this affidavit is to terminate the ownership that was created by the above mentioned
document.
5. That a certified death certificate of the deceased is hereby attached.
LOT 708, LAKEVIEW ESTATES 7TH ADDITION, ACCORDING TO THAT PLAT RECORDED JUNE 30, 2003
AS PLAT NO. 250 -E IN THE OFFICE OF THE COUNTY CLERK, LINCOLN COUNTY, WYOMING
State of tg1
County of 1, ss:
On the �a' personally appeared before me Margo Starnes the signer(, of the within
instrument, who duly acknowledged to me that THEY executed the same.
D. FENTON NOTARY PUBUC
COUNTY OF S 'a STATE OF
LINCOLN 1 'r,< WYOMING
MY COMMISSION EXPIRES OCTOBER 21, 2015
RECEIVED 12/27/2013 at 2:41 PM
RECEIVING 974739
BOOK: 825 PAGE: 865
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT of DEATH
MargoStap es
0 �y w
.�5
Notary Public 1 F-,.___
iL
TYPE oR
PRINT IN
PERMANENT
SLACK INN
.DO MOT USE
iet.ino
!Plt
onyeaticnotil
MANDBOMPS..
DISPOSITIO
PLACE OF
DEATH
DATE OF
DEATH
CAUSE OF
DEAN
ITEMS 32 3B
TO RE USED
FOR EXTERNA
CAUSES ONLY
(.011051311
.tor PEATH WS.
•PUE To OTNER
THAN NATURAL
CAUSES.
TI?E
C.OMPLE.TE AND
'CERMOCATE
STATE 0 IDAHO
STATE' OF :IDAHO'
1DAHo DEPARTMENTOF HEALTH ANDMELFARE
BUREAU OF VITAL RECORDS AND HEALTi*StATISTICS
Stale of Idaho
CERTIFICATE OF DEATH
i.oectoe,N,ra LEGAL NAMERncIPde AXAs rt ay) tt,fiqqta. Last, Suffn( •..2. SEX" 3, SOCIAL SECURIT1.NUMBERt
EUGENE' RAY SfARNES MALE
4, AGE.Lasi Birthday 4b.UNDER 1 YEAR 4C. UNDER DAY 5. DATE OFISINTH (Mo/DaY/Yr) 6: EIRTRFLACE /City and Siale. TendlOnt, or.foreignCOunlryt
Months Days Hours Minutes •1 ".`o 74 (Yeas) 12/05/1938 BUHL,IOA140
.Ya STATE OkFOREIGN'COUNTe4 7b COUNTY 7c. CITY OR TOWN
V IDAHO BONNEVILLE .IDAHO FALLS
c Jij,e'reiier:AND NUMBEO" •7e: APT. NO. '7f, ZIP CODE 7g, INSIDE CITy
178:VASSAR WO,. 63402
0 Yes .b• No
.2 S. MARITAL STATUS AT TIMEOF DEATH' SURVIVING SPOUSE'S NAME (II w r.
iiin ridio; n
ii:
I' Cgj Married 0 Married, but separated 0 Widowed 0 Divorced Never married 0 Unknown MARGO.,E(AINE IMCCOMA5.
lift FATHER'S NAME (Fir Middle.Last. Suills) 116, BIRTHPLACE' (Slithi, Tenitory, or Foreign"CoUjil(y)
LE.4 WILLIAM OKLAHOMA
2 a yo 7 :12a. MOTNERts NIMDENi4MEfFiral. Midrie 12ti," (Slate. Terdlry. or Foreign Country)
L
E r a- N
VIRGINIA BEATNICE.JOHNSON.
I 0 13a. INFORMANT'S NAME (Type or print) 146....Fiit.Ant*pHip TO13ECEBENt.l 3c. mAiLiaditibaxii (siroet;and N0;er. ci.iYSI1a.lzi
Z
MARGO STAI1NES 778 VASSARWAY• IDAHO FACI.„S, ID 83402
6. .14 OF DISPOSITION 15. PLACE OF DISPOSITION (Name and address of cemetery. •16. NAME AND COMPLETVADDRESS FUNERAL...FACILITY
03) Crerhation c/ 919 er P)aCA)
no .0,.PcmFil9 0 Enfornbruni EAGLE ROCkbREMATORY WOOD FUNERAL HOME
,.(aRatmityal from Idaho 173 NORTKRIOGEAVENLIE 273 NORTH RIDGE AVENUE
IDAHO: FALLS;ADAHO.83402 IDAHO PALLS. IDAHO 83402
;17.,•;.•0104ATURE OF FUNENALSERVIGE LICENSEE:OR 800500 40111f G AV SUCH i717.:11CiNii NUAAtitli (01 18....WAS CORONER CONTA&Eb
.13110 TO OF Dekoro:
ELECTRONICALLY.OILED: COBYE: BROWER SNP
I 10a. IF DEATH OCCURRED IN A HOS PITALf 19b. IF DEATH OCCURRED SOMEWHERE OTHEFetHAN A titiSlttlYAL:.
ID InpatiAnt: 2 0 ER/Ouludinl.3000A .4 °Hospce facility 5 0 Nursing home/Long 1,,., corp facility 6121Decadent's nom'. 70 oti, (Specify)
20 .FACILITY NAME (11 ripktacilIty, giSe strell•and nuniber1.,. 21,1ITY, TOWN, OR LOCATION OF DEATH, AND ZIP CODE 22. COUNTY OF DEATH
778:VASSAR WAY ADAHOFALLS BONNEVILLE
23. DATEOFBEATH'(Mo (Spell month) 24,77ME OF DEATH (246 "25. DedEFRONCONCER:OEAD(MO/DaYnifi) (SOO monlh) .26, nmePRONOUNCER:bEAD
January 24, 2013. '.itilinatad 2200 20l09: Jarpary S. 2013:
27. CAUSE o oeAti:I.
PART I. Enter the h in of events -diseases. injuries, or complications-11ml direclly causocl the deaik 00 3407 enteiierrnInevehts Such as cantiaC Aporoyirhato Interval,
u
7
rest se arrest or ventricular 9brillapon 0411,001 ul showing Put 91101053. 00 007 ABBREVIATE. Enter only one MAO on a linic Onset Id 00.314'
IMMEDIA'i'Eci■Opi,(Fin.1.
i8t ritfAiC CARDIOMYOPATHY 5 YEARS
;g1Nease•Petbndltion".' ...4
TO (or s a We uen" oft
Seguerilliilly lisieondiliona, b ATHEROSCLEROTIC:MEARTDIBBASE
...7, if enY. 'Skil/19 CRUM qui To (or as A dhseoli;;Ice ?1l' ?1l'
y, uNDERLYNd CAUSE 'CHRONIC OBSTRUCTIVEPULMONAR Y .1:0 YEAS
LAST.(diseese oi injury DUE TO (or as a cdniiouence oft
C ihai initialed !he overlie
resulting in death) HYPERTENSION
x
.1..... PART 11. Enter o_jjanifiCard, rsinditions colitillittlinoict death but not resulting In hp underlying cause gNen in
PO43 29a. WAS AN AUTOPSY 28b. WERE AUTOPSY FINDINGS
c
PERFORMED? AVAILABLE TO COMPLETE
THE CAUSE OF DEATH?
29.-DID TOBACCOUSE 0, IPEEMALE (Age9 554)
CONTRIBUTE TO DEATH? 0 pregnardWilhinOe%I.Year 0 Not:dregnent. 1403 piegnant 43 days
to i Yee 6a10ra dealt
0 Yei
0 ProbabN. 0 Pregnant al ilrofeof 'Oath Nalur1
unknown
E
0 1 pregna'At; bt 0 en, 0 ukr1oon:li pregf .Ylthinhe Past 0 0 InTn6
0 within 42 days ol death', Y' a *IicIikr 0 t.,,:oliki beiieio7ni3.4
iii 32,Z i AZO ti r y INJURY (Mo/Qay/yr) 33. TIME OF INJURY 34. PLACE OF INJURY (Dudent's home, farm'. slreel. construction site. 35. INJLERy
(S
p.0 m
nursing hoe, restaurant forest etc.)
ww
0 Yes 040
Slreel and Number or. Location
37. DESCRIBE HOW INJURY OCCURRED :IF TRANSPORTATION INJURY STATE THE TYPES(S)98 iiii:oci_i(s) INVOLVED (AutoMoble. oioffur molocite. ATV. Itiyht,•)
SPECIFY WHICH VEHICLE DECEDENT otcuPleo. if Sop9cable
TRANSPORTATION. pas. WAS DECEDENT: 0 Driver/Operator 0 Passenger ,3914. WHAT SAFETY DEVICES(S) DID DECEDENT USE/EMPLOY?
.INJUFECONLY..., ,-0.9,jjestrian
0.616. (S'OacifY) t 0 Seat belt 0 Child safely seal 0 Hemel 0 Air bag 0 None 0 Unknown
Ala..CERTIFIER (Check only.etly. based on o(ticialosoaciP/ Tor IhIs 66019E1) 396. LICENSE NUMBER
12;FLPHYOCIAN 0 PHYSICI4NAsslo't Atcr. 04DVANCED PRACTICE PROFEIONAL.NURiE N1 8..
7fi'lliatiest of 7 nY 0 00w 1 0 00 a. death occur/cod:al th and Olicit. antititai lo thapiff Catisa(yrnannar Oal
Q CORONER
.20e. o?p.s SIGN E!?
On the basis of esarnination and/ar inveslig116on. in my op(dioNsleath occurred at the time, dal
e, and place, and due.ldihe daPse(i)",
and manner staled
Signature and Title of Cendler 14 PATRICK D. GORMAN, M.D. 'MM P
...gr0.747tit* ADDRESS, ANG•ZIP CODE 08 CERTIFIER (Type 0 prinl)
PATRICK D. GORMAN2001; 5, W0
This is a teve and correct' reproduction of the document officially registered and placed
On file witli: the IbAH0.01:01EAU OE VITAL:RECORDS AND HEALTH STATISTICS.
DATE ISSUED: bla/Vidal 141,10)
.This .copy not valid inflePs preparkdon engraved border
and signature of the Registrar.
rna4i000n0Viz.
JAMES .)3. XYDELOTTE
ISTATE REGISTRAR .1
ISTA'TE REGISTRAR
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