HomeMy WebLinkAbout975389STATE OF UTAH
ss.
COUNTY OF SUMMIT
AFFIDAVIT OF SURV`WORSHIP
975389 2/21/2014 12:56 PM
LINCOLN COUNTY FEES: $21.00 PAGE 1 OF 4
BOOK: 828 PAGE: 386 AFFIDAVIT
JEANNE WAGNER, LINCOLN COUNTY CLERK
11111111111111111111111111111111111111111111111111111111111111111111111
II IIII
DAVID JAY HOLMES, being first duly sworn upon oath, deposes and says:
That he is the appointed Personal Representative of Jacqueline Holmes Miller, also
known as Jacqueline Holmes, who died a resident of Lincoln County, Wyoming on October 15,
2013 and is named as the decedent in the Certificate of Death hereto attached and by this reference
made a part hereof.
That said decedent is one and the same person as Jacqueline Holmes, who is named
as Grantee and vested owner by Tenants in the Entireties with Billy J. Holmes, Grantee, on that
certain Warranty Deed recorded March 23, 1966 in. Book 73 at Page 415, in the records of the
Lincoln County Recorder, Lincoln County, Wyoming, which concerns the following property
located in Lincoln County, Wyoming, to -wit:
LOTS NUMBERED FOUR (4) AND FIVE (5) OF BLOCK NUMBERED SEVEN (7)
OF THE ORIGNAL TOWN OF COKEVILLE, LINCOLN COUNTY, WYOMING, AS
SURVEYED, PLATTED AND RECORDED TOGETHER WITH ALL BUILDINGS
AND IMPROVEMENTS THEREON OR THEREUNTO IN ANYWISE
APPERTAINING.
That Billy J. Holmes died on May 31, 2000. An original death, certificate is attached
hereto by this reference and made a part of this document hereof
That David Jay Holmes, as personal representative of Jacqueline Holmes Miller, is
the lawful vested owner of the following real property as the Successor in Interest following the
deaths of Billy J. Holmes and Jacqueline Holmes Miller, also known as Jacqueline Holmes.
DATED this is day of February, 2014.
DAVID JAY I TOES
STATE OF UTAH
ss.
COUNTY OF SUMMIT
On the i K' day of February, 2014, personally appeared before me, DAVID JAY
HOLMES, the signer of the foregoing instrument, who duly acknowledged to me that he executed
the same.
NOTARY PUBLIC
AL RECORD
IIIII r,
DECEDENT
PARE NT--
INGI/Nhlor41
061 MO
61
PERMNENT
FOR
INSTRUCTIONS
SEE
HANDBOOK
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1 t. NMS OEQEDENT EVER Vi U.& ARMED FORCES?
MAPCO' a ne) I li
No
11 4'LpCAL FE.ENUMBER 1009
1. DECEDENT -NAME FIRSY,
BILLY
a. SOCIAL SECURITY NUMBEIV.
7a PLACE OF DEATH (Check only. a.)
f hpetlant 0 ER/Outpatient o OOA I
76. FACILITY NAME (4 not kstegthe phe rime we .W,bn)
225 Post St.'
B STATE OF BIRTH (4 not it U.SA.1 sate country/
13e. INSIDE CITY LIMITS?
(Speed yen, or no)
Tea
29: MANNER OF:DEATH
158193
vAgr 1161 EnMr the dhausa, L
28. a nplralory I arr.lM
IMMEDIATE CAWE (4)411
OYeaee oa condition
resulting In death) 4
21a RAI. r LID- -EE
a I 014 eelaye►
(&V40.* ono Me)
228. DATE SIGNED
13b. COUNTY
DEPARTMENT OF HEALTH
STATE OF WYOMING
OF HEALTH
CERTIFICATE OF DEATH
Li"neoln Gokev .11.e
14. VAS DECEDENT OF HISPANIC ORIGIN?
(6pse6y no or yes B tee, epedty
Clan, Mexican, Puerto_ Rican, Ela(
No 1 wed (Speed)
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es
et Print)
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del4.ne
1 BEET OR R .0.:NUMBER CR7 OR TONIN
a.o Y�Srominrt 831114
20 44Y, W.) 208. cEL1E7ERY OR CREMATORY- NAME II
Btiral J urie 13,, 2000 Cokeville Cemete
DISPOSITION
CERTIFIER
Of Di 1,11:
thews /Aorta
22c. HOUR OF DEATH
9130 AMM
THAN CERRWER
22d. NAME OF 3�' P1IYBICI R OTHEIj (AP a PrM)
2a NAME AND ADDRESS OF CERTIFIER (PHYSICIAN OR pORONER)17/P. a Pdnt)
Dr. chris P.r411., 711 Onyx St., Kemmerer Wyoming 834
254 REGISTRAR 1 I II rl 1
wow
DUE TO (OR AS A CONSEQUENCE OF):
0x re,iuc;<
DUE TO (OR AS A CONSEQUENCE OF):
DUE 10 (OR AS A CONSEQUENCE OFI:
MPT W OTf1ER 84NIFICANT CONd71ONS Cax9lbn 00.40(6.0446 death but not noted to cause Own in PART L
30b. TIME OF '1
This is a true and exact, Ceproduction,ol the document on file in the office' of Vital
_Records Services, Cheyenn'
iml�g
DATE ISSUED:
HOLIES
SP. UNU4N 1 -reAR
WEN 1 DAY
MI mAse
Hanna Hof' 1 Residence 0 Other (8pid I.
7c CRY.194M, OR LOCATION OF DEA
Coke
9. MARRED, NEVER MRIE
ND, 10 BURVMNO SPOUSE (M h(h 9h+ o
WI0OWE0, DIVORCED (S*c67) I I' Iv
Married Jacgn ne u
12a. USUAL OCCUPATION .(04. NW e( Mont dprs d.H4
*neap We. thew NNW
Miner
Phoaphta(te. Mining
13d. STREET AND NUMBER
225 Po$'
c St.
ID, RACE -M. an.Wlan, I8. DECEDFM'S EDUCA1WW
Oath, While, Ea Pe only highest 4640 (s oa1Pleled)
(4.411Y)
18. M NAME First
on
19b.REU1
26; KIND OF BUSINESS OR INDUSTRY
711 tl r,OUNTY OF DEATH
9r II 4� nc9
MIMIIIII I,1 IIII III i
1 rll
STATE FIIE NUMBER
Iu ATE O,f DEATN (Ah, iI II M ull Ij 1 1 1 n l
!31, 2000
8 DATE OP, BIRTH (MO. Dap. 8..)
Sept. .8,.1931
TOOE_CEDENT
it I I 11 I II 1 11
1! I II i 1 IIII IIII 6 1 1
Sot (.00 A T I d (ISt1eYl, l 4nd Num Ravel tMenber Cie
1 19V IIIIpI�i
2
40'1'30 j h
Lucinda.Mccaffr y
Deputy State Registrar
This co is not valid unles P'Ne aced on Pa Per wdM displaying '11[1. 1 d II
'q (IIII I
9 P Y Registrar. e 111
py s p p p an en raved border the date, seaLand of the De ul State
Maiden Surname
I Ir'r111
III I qb: IIII',
2Od.LOCA 24Ifl! IIII tlRY,OR'V :SUT u1 I I
YJ] %i rnp u911' Tull
Der 214 ADDRESS tlP ly( "I 1 1 111 1
MOlTt e e
er Idaho
234 PRONWNCEO Rhv�
1 1 AD
Iln 6
I oneet: and 044th;
I
I II p 1, 1 11 ,9111I�II
III' I 'P!l III Itiutl6i
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Art
a b il�a
;oxen _'f
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Place of Birth
Armed Services:
rSpouse's Name:
Industry/Business:
asideaoe
Mother's Name
Ea alit y-Yaz Address:=
Date, Registered: October 17, 2013
Date sued -Octol er 8, 2013
CERTIFICATION OF VITAL RECORD
.4Y1'Y •Yt S�VV .tt 1h.f. •S. 1.•e1Ye.1r 1J:tYVPVf4M .f
Montpelier; ~Idaho
No
Miles Melvin Miller
U.S. Postal Service
Nampa, Idaho
Pauline Stoner Larsen
60;'Sagewood Way Coalville, U.T: 84017
NFORMANT INFORMATION
Name: David Jay Holmes Relationship:
Mailing Address: P.O. Box 348, Randolph, Utah 84064
DISPOSLTE INFORMAT[O
Method= ofDisposition RWmoval
Place of.Disposrtlon=_ C6kevi ie=Cemetery, Wyoming
Date of Disposition. Octbber 19, 2013
FUNERAL HOME INFORMATION
Funeral Home Crandall Funeral Home
dar_ess: PO B 6;.105 East Center Street Kam°as Utah -84036
Funeral Director VUlliam W;BalI
MfD, ICAL CERTIFl¢ATION
Medical Professional: Donald W Allen MD, PO Box 865, Coalville, Utah 84017
CAUSE OF DEATH
Lung Cancer SmalLCell [Onset: 2 Years]
Tobacco Use Non -user
MedicarExaminereontacted Yes_. Autopsy Performed: No Manner of Death Natural.
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_This is an exact _reproduction of the document registered in the State Office ofVitalStatistics
Security features of this official document include: Intaglio Border, V &A images in top cyc(oids,
ultra violet fibers and hologram image of the Utah State Seal, over the words "State ofijtah This
p Y signature g r d tY
I ncument dis la s the date, seal si nature of the State Re istrar and 'the County/District /District Healt h Officer.
IIII 11 1111 1 1 1111 DI Richard Buifougfi
Janice L.
Houstoit State Registrar 0 6 3 6 1 2 3 Director/Health Office-
Office of Vital Statistics County Health DepartMent
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