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Hiokmn
arid` 1i1eCo
SINCE 1904
976148 4/16/2014 4:06 PM
LINCOLN COUNTY FEES: $18.00 PAGE 1 OF 3
BOOK: 830 PAGE: 569 AFFIDAVIT
JEANNE WAGNER, LINCOLN COUNTY CLERK
1 1111111 VIII IIII IIII I11111 II1111111II I (IIII hill i III IIII I1II I I III IIII IIII
AFFIDAVIT
I, BILL S. JESSON, being first duly sworn on oath, depose and say:
That I am a citizen of the United States of America over the age of 21 years, and a
resident of ARIZONA
That I was well and personally acquainted with ANN L. JESSON in that certain
Warranty Deed dated SEPTEMBER 7, 2005 and recorded in Book: 596, at Page: 795, as Filing
No. 911603 in the office of the Recorder of LINCOLN County, Wyoming.
That I know of my own knowledge that ANN L. JESSON in the said deed and ANN
LOREE JESSON mentioned in the attached Certified Copy of Certificate of Death was one and
the same person.
This affidavit is intended to terminate the TRUSTEE, ANN L. JESSON, in the BILLY S.
JESSON and ANN L. JESSON Trustees, of the BILLY S. JESSON and ANN L. JESSON
REVOCABLE TRUST, dated September 17, 1997 in the following described property:
LEGAL DESCRIPTION
Lot 233, Lake View Estates Subdivision, Tract "A as filed and platted in the Lincoln County Clerk's
Office in Kemmerer, Wyoming
Now none as:
Lot 839, Lakeview Estates 16 Addition to the Town of Alpine, according to the official plat filed May
23, 2008, as Instrument No. 939245 in the Lincoln County Clerks office, Lincoln County Wyoming.
Tax Roll No. 12- 3718- 29 -4 -17- 060.00
Dated this day of Mri.,(04 2014 A.D.
BILL S. JESSON
x -1‘; /76/
LH
(/J
63930
STATE OF
County of
Commission expires:
Residing in: rc coo
INDIVIDUAL ACKNOWLEDGMENT
SS
On the -day of A.D. 2014 personally appeared before me
the signer(s) BILL S. JESSON of the within instrument, who duly acknowledged to me that
he/she/they executed the same.
..g71 JAMMIE L Pr?rir
Notary f-vizona
My Cot Expires
August 2, 2014
C. 'sr V. V ir cES
otary Public
LH
B. MIDDLE a LAST
DECEASED
1. ANN LOREE JESSON
SEX
2, FEMALE
DATE OF MONTH DAY YEAR
DEATH
3. OCTOBER 3, 2005
RACE (e.g., white black, American Indian, (specify tribe)etc.
SPECIFY
4A. WHITE
OF 1- ORIGIN:
1 ,ET?E litS 0 N7 90
(Ag:
48 NO
IF YES. INDICATE MEXICAN, SPANISH, PUERTO RICAN,
CUBAN, ETC.
4C.
WAS DECEASED EVER IN U.S. ARMED FORCES?
(SPECIFY YES OR NO)
s. NO
PLACE OF 6A. COUNTY
DEATH
MARICOPA
69. TOWN OR CITY
MESA
6C. HOSPITAL OR (IF RESIDENCE, GIVE STREET ADDRESS)
INSTITUTION
BANNER DESERT MEDICAL CENTER
6D.
0004
0 OP EMER,
VIN PATIENT
DATE OF MONTH DAY YEAR
I\ ilik, 7: JAIsiDARY, 2:•,,...194
AGE (YEARS
LAST BIRTHDAY)
8A. 64
IF UNDER 1 YEAR
MOS. DAYS
86.
IF UNDER 1 DAY
HAS MIN.
(30
MARRIED, NEVER MARRIED,
WIDOWED, DIVORCED (SPECIFY)
a MARRIED
SURVMNG (IF WIFE, GIVrMAIDEN NAME)
SPOUSE
10. BILL S. JESSON
s., efnoti4 USA; name country)
'191,5Y OF E9_,011_
'1 i GxEgLEy i COLORADO
KT3,7, SPECIFY
12 U. S A.
SOCIAL SECURITY NO.
13.
USUAL OCCUPATION (Give kind of work
done most of working li(e, even if retired)
14A TEACHER
KIND OF BUSINESS OR INDUSTRY
148. EDUCATION
USUAL 154. STATE
RESIDENCE
15 ARIZONA
158. COUNTY
MARICOPA
150. TOWN OR CITY
TEMPE
1 OW. ZIP CODE
85284
HOW LONG (0 ARIZONA?
16. 9 YEARS
EDUCATION
HIGHEST GRADE COMPLETED
17.
STREET ADDRESS OF R.F.D.
DR
15E 9790 S. GRANDVIEW
INSIDE CRY UMITS?
(SPECIFY yes or No)
13 YES
ON RESERVATIONS
(SPECIFY Yes or No)
15 G. NO
PREVIOUS STATE
OF RESIDENCE
10 COLORADO
ELEMENTARY SECONDARY
(0-12)
184
COLLEGE
(1-4 or 5+)
189. 4
FATHER'S A. FIRST B. MIDDLE C. LAST
NAME I
19 RICHARD IRVIN O'GAN
MOTHER'S MAIDEN A. FIRST B. MIDDLE C. LAST
NAME
20 MABEL HENRIETTA LINDBLAD
INFORMANT'S SIGNATURE 1:1?Atellisto
ii'llill ItIi
l,AlitI21* S. LJESSON
RELATIONSHIP TO
DECEASED 'i
22 HUSBANIY
ADDRESS STREET NO. CITY AND STATE ZIP CODE',
t•
23 9790. a., GRANDVIEW DR. TEMPE AZ 8;
2M
CERT. 00
278.
01:441AL d4p944TioN,,,,
4REMOVAL:011ERISPedlY),''
6
A. CREMATION
DATE
25 10-12-05
CEMETERY OR CREMATORY- NAMEALCATION I
GREENWOOD MEMORY LAWN
26 CREMATORT" PHOENIX AZ
EMBALMERS SIGNATURE
27/!.P NOT, E
FUNERAL HOME NAME STREET ADDRESS '.•''.•iii. ca:Y.. AND STATE
i'i 0 '1 'I'
28. NATIONAL CREMATION SOCIETY 4460 E THOMAS RD, FHOEN11;'AZ85,910'
RUNERAL DI' i t i i •i' g as c GNATURE)
29x TRO 4 L RICAHRDSON
CERT. N0
me. F1065
g z
1. E i
R
ffi r7
illiflg Ilti i
TO THE BEST OF MY KNOWLEDGE, DEATH OCCURRED AT THE E, 0475 400 PLACE AND
DUE TO THE CAUSE(S) ED.
30. SIGNATURE h„
AND TITLE r 0 010r "...ileigefririii 1
.._-..t..........
I 'i
w
R:,-
ON THE B
AT THE TIME,
34. SIGNATURE
AND TITLE
SIS OREMMINATION '0/09 INVESTIGATION, IN MY OPINION DEATH OCCURRED
DATE AND PLACE DUE TO THE CAUSE(S) AND MANNER STATED.
,Its
0410 SIGNED No.. Day, Year)
31. OCTOBER 4, 200 IP
32. .06 P":11'
4 6
DATE SIGNED (Mo., Day, Year)
HOUR OF DEATO
NAME ORTTENDING PHYSICIAN OF OTHER THAN CERTIFIER (Type or print)"
3 t„,
f130NOUNCED,DEAD (Mo., Day, Year)
PRONOUNCED DEAD (Hour)
14
1 1. ;I lre l rir A .POtold4
SS OF CERTIFIER, PHYSICIAN. MEDICAL EXAMINER OR TRIBAL LAW ENFORCEMENT AUTHORITY
MD 1435 S. -DOBSON RD. MESA, AZ-2
'A FORCREMATTON
(J E91 4
V_ No
(3
MED 11RE
4
DAMegGISIEREli ffin
I
REG. FILE NO
43. 2
REGIS S SIGNATURE 1 i AF is
44 ill 11 ,A....„ la .4' IP,' 1. ..i.
C
REG. DIS
45 1
STATE OFFIC
2 i l gl'
u.. r.$ g°
i P 5 1E 4 a
C 1-•
47A. IMMEDIATE CAUSE (FINAL Di S E 0 00001 ON RESULT! 1 GiN DEATH) (E P NLY CAUSE 04 CH LINE)
1
rr‘" t 4 s 9, s""k"*.e.i ..-c....: ILA rc,..,,,
APPROXIMATE
INTERVAL
BETNEEN
ONSET
AND
DEATH
4713, DUE TO OR AS A CONSEOUENCE OF:
Se' ‘S'
47C DUE TO OR AS A CONSEOUENCE OF:
Y% A Lc c- C-'--" c_t-A
T ti.;011imrskAiii'cant nrthditinriiIt'ontlibyting to death but not resulting in the underlying cause given in Part I
p,
AUTOPSY
(Specrly Yes or No)
49. NO
WAS CASE REFERRED' TO MEDICAL EXAMINER"'
(Specify Yes or No)'
50. YES
MANNER OF DEATH
NOEL M1 -FA r
ou m
III. NI pananu
ImIll 600 we INESTICATIGN
wax UI:EIEFIYINED
51.
DATE OF MO DAY 70
INJURY
52•
HOUR
53. M
INJURY AT WORK?
(Specify Yes or No)
54.
DESCRIBE HOW INJURY OCCURFiED
55.
PLACE OF INJURY (At home, term, street factory, office building, etc.)
SPECIFY
56.
WHERE LOCATED? STREET ADDRESS CITY OR TOWN STATE
57.
rona
Department ot
fiea Eli `lerk
VERIFICATION BOX" (HOLD BETWEEN THUMB AND FOREFINGER, OR BREATHE ON IT. COLOR WILL CHANGE TO BLUE AND THEN RETURN.)
ANY AITERATION OR ERASURE VOIDS THIS ITOTUMENE
????;2fT
SUPPLEMENTARY ENTRIES
STATE OF ARIZONA
STATE OF ARIZONA
DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS
CERTIFICATE OF DEATH
PATRICIA' ADAMS
ASSISTANT STATE REGISTRAR
Oct 17 2005
This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS,
ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA issued under
the authority of A.R.S. 36-341, and by direction of:
This copy not valid unless prepared on a form displaying the State Seal and impressed with the raised seal of the issuing agency.