HomeMy WebLinkAbout975149When recorded mail to:
Beverly N. Gomm
1272 E Manfield Way
Draper, UT 84020
AFFIDAVIT AND ACCEPTANCE OF TRUSTEESHIP
Comes now the undersigned Beverly N. Gomm 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, E. Merrell Gomm
3. That said deceased. is one in the same person as E.Merrell Gomm listed in that certain document as
recorded on fj at Entry No.7S'3S_ in Book 7 at Page 5 'a in the office of
the Lincoln County recorder, State of WY.
4. That the purpose of this affidavit is for Beverly N. Gomm to accept the Trusteeship of the E. Merrell
Gomm and Beverly N. Gomm Trust dated June 2, 2005 and hereby agree to act as Trustee of said
Trust on all the terms, provisions and conditions specified in said Trust.
5. That a certified death certificate of the deceased is hereby attached.
Legal description:
ALL OF LOT 4 OF THE GOMM FAMILY ASSOCIATION SUBDIVISION AMENDED, LOCATED IN LINCOLN
COUNTY, WYOMING, AS DESCRIBED ON THE OFFICIAL MAP AND PLAT THEREOF FILED NOVEMBER
14, 2008 AS INSTRUMENT NO. 943628 IN THE OFFICE OF THE LINCOLN COUNTY CLERK.
State of V +a h
County of S4 t-€i' ss:
On November 55 2013 personally appeared before me Beverly N. Gomm and the signer(s) of the within
instrument, who duly acknowledged to me that she executed the same.
NOTARY PUBLIC
JOSH EPPERSON
666421
COMMISSION EXPIRES
MAY 7, 2017
STATE OF UTAH
975149 1/31/2014 1:24 PM
LINCOLN COUNTY FEES: $15.00 PAGE 1 OF 2
BOOK: 827 PAGE: 659 AFFIDAVIT
JEANNE WAGNER LINCOLN COUNTY CLERK
11111111111111 111111!1 IN 1111111111HI!! IIIII111IIII11I11III
Beverly N. Gom
Nota
Com
ublic
ission E yes: 05704-/(7.,
CERTIFICATION OF VITAL RECORD
ca rs AUG 1 2006 STATE OF UTAH DEPARTMENT OF HEALTH 1Oi)b 0'' 8 0' 5 3
M41 14wI:; CERTIFICATE OF DEATH STATE FILE NUMBER,
ryt Ru4s LOCAL FILE NUMBER I L 9 c
DECEDENT'S LEGAL NAME (Jnckude ;AKA's. il'any)(Firsr, Middle. Last) 2 SEX 30 OATE'. OF DEATH (Mo., Day, Yr.)
E 'Merrell Gomm Male July 31, 2006
5. AGE- Last IF,UNOER I YEAR IF UNDER 24 (IRS
Birthday (Years) Month
4. 04,7E QF BIRTH (Mo.. Day. 9c)
June _20, 1 1926
B PLACE OF DEATH (Check only one) (p a
�(j� IF OFJITH OCCURRED IN A HOSPITAL. I IF DEATH OCCURRED SOMEWHERE OTHER THAN 6 HOSPITAL:
Home
0 '1 0'1 Inpall¢nl ER/Outpatient 3.006 i 5:'Nursing H4me/L gterm care facility 0 O 7. Other 5 eci ry Auto Accident
7'3.20 89, 4619 OF HOSPITAL :NURSING HOME OR OTHER FACILITY( /f oulsido a fly. OW. 8c COUNTY OF DEATH ed. CITY, TOWN OR LOCATION OF I DEATH
ECEDENT street address oflocal(n I
19001 )Cain Street Utah Lehi
9. WAS DECEDENT EVER IN 1 MARITAL STATUS
THE U.S. ARMED FORCES 0 1. Never Married
®1. Yes .0 2..No El 2. Marned. 0
A r^1 120.. DECEDENTS USUAL OCCUPATION(Glu Iind or work
C 7 done dunng most of wonting lie. Do NOT enter retired:
Teacher
13b. STATE r. 13C. COUNTY
1,. Ca137fornia Los Angeles
14: FATHER'S. NA1.49 (First .Middle. Lest)
.Ben Charles Gomm
INFORMANT
DISPOSITION
374- 2-43
OERTIFIE
CAUSVOF
e '.L --I-
ol
UDOH)OVRS
Form 12
Rev 11/30/04
EGISTRAR
16: NAME, RELATIONSHIP-AND MAILING ADDRESS OF INFORMANT (Skeet 6 Number, Cdy. ate, Zip)
Bryce Charles Gomm Son
17 198780009 DISPOSITION
1. Enna/admen( 3 Other r1 5 G lbn
2. 00nalion pLi4. BON 1 1. 110. Removal
1 8c. LOCATION OF DISPOSITION City aura
Millville, Utah
21,$1GEIAT1WEa0F„FUNy1AL SERVIC IC
22 (Checkon/y one y:
rI J�1. CERTIFY PH YSICIAN: To the besl•1 my knowledge. death occurred al the time, dale. and place. and due 10 the Cause(s)' and manner as s
In 2. MEDICAL EXAMINER: On the basis of examination and /a investigation. Inmy opinion. death occurred al the um ale. place' and due to the causes(S) and manner es stated.
M E: Case No,
/o'9' SO�
THE CAUSE H (Item 24) (Type/Print) 23b.
e st� 151.78 D CEAED WAS S LAS vc
TATTENDED
23i.. :NAME,ADORE$S D ori a n CODE FOR PERSON W CERTIFIED I C SE OF DEATH y i �Lr�- Wl 'a 1tM✓t A
S�PI -tr�l �Dn1 I�cx�
24, pART I. Enter Pie Id f event diseases, In) or comptIcanons•ihal dlreElly caused the death DO NOT enter terminal events such as cardiac ces., resp iratory (A le Interval
bream, or ventricular e I a
cagy. DO NO ABORCVIAT Enter 021)/ ode cause on a Ilse. �fwee Onset antl
reel/Wog In deaihr e"7
IMMEDIATE CAUSE (Fine a.
OVE 1 (OR A A CONSEQUENCE OF):
Saquentielly ens, U b
Medi. to the a C
IMaase DUE TO (OR AS A CONSEQUENCE OF(::
ants d.
PAR 9. Other 1 Conditions contiibOlin° to death but not resulting In Inc underlying cars given in Pan I
SIGNATURE B'TITLE OF CERTIFIER
26.'IN.YOUR OPINION. TOBACCO .18687 THE DECEDENT: 27. MANNER OF DEATH 28. IF FEMALE
'0'1. P bably Oentribu10d to the cause of death. 1 Nalur,al S1 Accident 1. ,N at pregnant 'within past year
2. Wa e undsnyl g 034.0 01 death UNKNOWN 3. S ,OIde 4 Homicide I r 2�. P egnanl el Date of death
Could not
g
•3 Did 1 contribul to the cause of death.
th IF USER u 3. Nal pregnant, 1301 pregnant within 42 days 1 death
4 '1 k ow In relalIOn to the cause of death.
n' 5. Oelermine d 6 Pending
tl Investigation n 4. U pregnant, but pregnant th days 101 year th
before dea
MI 5. Unknown nown i1 orepnHnl wllhin the pest year
290. DATE OF IN URY (Mo., Day, 7,.) 29b TIME OF INJURY 290. IN:IURY AT WORK7 290. PLACE OF INJURY -A( AOme, ran. street„ 2�e ((160(41 v�l lcle bccidanL
(24 hr. Clp (acfoty, o/(/ oudd/nq, aft, ($peGl t a L 1 1 Of U_ 2. NA as5enger 7 Peee
3 el/ 16 ❑t. Yes �.No... lG.l, 17r1'J •,.f, /r 7r e.0 {h �Unknpwn
9f 1 TION(St..(0,.090( rrobe number, city 010101, county 29g. DESCRIBE HOW. INJURY OC U RRED(w0n oeyvence 09 events which resin led /n/ry1/99. TURE t)9 INJURYould 00'.
4,f 11 j yQ a s r,� C 0(0,00 n Oen) 24)•v .1-� n• l e.. c± sr, t7Ju curl
�a I ri `�'rrrtil_ �ru �.1c: ,w::xrY:l {v.�c.lc
{7t(A kfr What tae
05 WAS OECE0091 HISPANIC ORIGIN (Check the 'No ow. 31. DECEDENTS RAGE (Check artery InOM. races to indicate what the
10104001 Ja'n0f Spm4Meapanetafrno. *00Oml cols1lered n(nsed a herself to bet
u Yds ®2.NO ®O. whoa ❑o2 sea at AMean Ama,un
f it yea, Chet$ Ink boa 9101 6W desnlbes whether 101 0.c4era W. Am can lnOlan Or Alaska Na0,0 (N.M. or Ow enolnd orpdndpal tries)
is SpenkM411e*rdoleo o
I. no.. 000,00,, Mexican Ameresn. Chicano
2. 06a, Cuban
2 Yee. Pvano Rican
❑4,Yn, time,Soa4040i0000WLa1IM (sptt3M f
18a DATE OF DISPOSITION
August 4, 2006.:
DUE TO (OR AS A CONSEQUENCE OF):
Barry E. Nan I
Y Nang
le
Registrar
Stale 19. LICENSEE NUMBER
93-103379
80618
(,1
M. GN0.
0 08.NeeseHawn
00 Caner Avan ISpe0Jry)
,0. Avon (titan
12. Samoan N. Nptnanese
1 Guamanian or C5ammm
15. 0100/80610 Islander (01001N1
000. 0/her (5peRRI
6 BIRTHPLACE (CO 8 Slate or Form Country)
Afton, Wyoming.
5 MOTHER'S NAME PRIOR TO FIRST MARRIAGE (Ewa la fiddle „Last)
Opal Louise 'Allred
3836 South Pavant Drive West, .City, Utah
tab. PLACE OF DISPOSITION Memo or cemetery, crematory. °rather place)
Millville City Cemetery
20, FUNERAL HOME (Name and oomplela address).
Jenkins-Soffe South Valley
1007 W. So. Jordan Pkwy
South'Jordan, Utah 84095-
25a. WAS AN AUTOPSY
PERFORMED?
0 1, Yes 2. No
7, SOCIAL SECURITY I NUMBER
Confidential
I1. SURVIVING SPOUSE'S NAME.: Matte, 9Nename error to Oral parr /age)'
3. Widowed 5 Married, but separated
4. Divorced' 0 6, Unknown Beverly Motel Neves,,.,,
120. KIND OF BUSINESS OR INDUSTRY 13e. RESIDENCE STREETANO NUMBER
Elementary School 526 E. Fourth Street
(3d. CITY. TOWN. COMMUNITY. OR RURAL 13e. ZIP C00E
Azusa. 91702
31. INSIDE CITY LIMITS?
E I. Yes 2. No
84,120
22a. Was Medical Eaarriner Contacted?
E 1. Yes ❑2, No
250. WEREAVTOPSY FINDINGS AVAILABLE
PRIOR TO COMPLETION I OF CAUSE OF
066(87 0 1. Yes
32 DECEDENTS' EDUCATION (LIMO the
boa that beat clear/tea the OEOele degree Jr
0601°0 school completed 1114 lane ofdaath.)
l::elh Oradea 011
2,.610. l l h grade', 00 dlplama
0. Rion School ara4uale a GEO templet.
0 4. same cog ogioN. o, 0.10 00400,00
1 05. Assoc/we degree b4,.M ASI
108. BMhobrs oopea (e.p BA. A8.018)
1E7. Mat a., doorvs leap MA. 015, MErq,
a 000wral. (e.0., PhD, E401 or Prolesvorlpl
degree (ea.. MO. 005.:0001, LLB. JCR
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 displays the
date, seal and signature of the State Registrar of Vital Statistics.
Updated Utah State Seal replaces hawk over valid for. authenticity.
UTAH DEPARTMENT OF HEALTH
Office of Vital Records Statistics
Salt Lake City, Utah