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Home My WebLink About9765641 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 976564 5/8/2014 3:48 PM LINCOLN COUNTY FEES: $21.00 PAGE 1 OF 4 BOOK: 832 PAGE: 138 CERTIFICATE JEANNE WAGNER, LINCOLN COUNTY CLERK III III IIIII IIII III II II II II II I III III IIII IIIII I I1 II IIII I I III III III APN #138 -21- 118 -053 STATE OF NEVADA COUNTY OF CLARK CERTIFICATE OF INCUMBENCY AND CERTIFICATION OF TRUST NRS 164.400 i ss. ALAN L. BUCHHOLZ, being duly sworn, deposes and says: CLARK COUNl,..VADA FRANCES DEAI O RDER 20040304 0 3 6 6 6 RECORDED AT THE REQUEST OF: JOHNSON JOHNSON 03 -04 -2004 15 :23 OFFICIAL RECORDS BOOK /INSTR:2004®3 03660 PAGE COUNT: 4 FEE: 17.00. RPTT: .00 1. ALAN L. BUCHHOLZ and MARY D. BUCHHOLZ created a revocable living trust on March 14, 1997, entitled the BUCHHOLZ 1997 TRUST. 2. ALAN L. BUCHHOLZ and MARY D. BUCHHOLZ were named in said trust as the initial Cotrustees. The Trust grants all of the powers set forth in Nevada Revised Statues 163.265 to 163.410, inclusive. 3. MARY D. BUCHHOLZ, one of the initial Cotrustees, died on January 14, 2004 and a copy of her death certificate is attached hereto. 4. The trust instrument provides that the surviving Settlor shall serve as sole Trustee. The undersigned, ALAN L. BUCHHOLZ hereby accepts the trusteeship of the trust and agrees to be bound by all of the terms and conditions thereof. 5. The form in which title to assets of the trust is to be taken is: "BUCHHOLZ 1997 TRUST, dated March 1.4, 1997 ALAN L. BUCHHOLZ, Trustee" 6. Real property (real estate) currently held in the trust includes: (see Exhibit A, attached). 7. The trust has not been revoked or amended to so as to make any representations contained in this certification incorrect. 8. The signature shown below is that of the currently acting Trustee. 9. This certificate is made pursuant to paragraph B.12 of the trust and according to Section 164.400 of Nevada Revised Statutes. CDO SUBS this Dated FEB 2 7 2004 RIBED and SW B 2 7 2004 N TARY PUBLIC Please return to: Johnson Johnson 530 S. Fourth Street Las Vegas, NV 89101 RN to befo me by Alan L. 20040304 03660 A-20 ALAN L. BUCHHOLZ 8301 Swan Lake Avenue Las Vegas, Nevada 89128 Notary Public State of Nevada County of Clark THERESA M. THACKER My Appointment Expires No: 98- 3365 -1 June 12, 2004 Mail tax notice/bill to Trustee(s) whose address is: 8301 Swan Lake Ave., Las Vegas, NV 89128 ;DECEASED -NAME First Middle Last :A., Many Diamond. BUCHHOLZ DATE OF'DEA Month, Day, Year) 2. January 14, 2004. COUN OF DEATH' COUNTY OF 3i., Clark V TOWN:OR LOCATION OF DEATH Las' Vea-as HOSPITAL OR OTHER INSTITUTION —Name (If not either, give street and number) 3c. Susserlln Hospital Medical tenter If Hosp. or Inst: Indicate DOA, OP /Emer. 3 e lnp inpatient SEX 4. Female ,RACE—(e.g., White, Black, American 'Indian, etc.) (Spec a.. White. -Was Decedent of Hispanic Origin? Specify Dyes no If yes, specify Mexican, Cuban, Puerto Rican, etc.. iv s. AGE —Last Birthday (Years), 7a. 59 UNDER 1 YEAR MOSS DAYS' 7b. UNDER 1 DAY' ',DATE OF BIRTH (Mo, Day, Yr.) 8' Aug 2�i, 1944 .:HOURS MINS ze STATEOF BIRTH (If not USA., mine country) _Da Calif CITIZEN OF WHAT COUN- TRY all U. S. A. Decedent's Education. Specify highest grade completed. 10. 14 MARRIED, NEVER MARRIED, WIDOWED,. DIVORCED iSpecit11arr led: 'SURVIVING.SPOUSE (It wile, give maiden name) 12 Alan L. Buchholz .SOCIAIJSECURITY'•NUMBER 13 USUAL OCCUPATION (Give Kind of Work Done During Most of Working Life; Even if Retired) 14a. Homenfaker KIND OFBUSINESS OR INDUSTRY 14b.. Own Home RESIDENCE —STATE 15a Nevada COUNTY 15b. Clark CITY, TOWN, OR LOCATION 15c.. Las Vegas STREET AND NUMBER 15d. 8301 Swan Lake INSIDE CITY LIMITS (Specify Yes or No) 15e.' Y.es i FATHERNAME First Middle Last 16. Jack Diamond MOTHER MAIDEN NAME First Middle .Last 17•; N ina Lawrence :INFORMANT NAME, (Type or Print) .Alan L.: Buchholz- Husband MAILING ADDRESS (Street or R.F.D. No., City or Town, State,. Zip) 18b. 83@i Swan Lake, Ave. Las Vegas, Nevada 89128 BURIAL CREMATION REMOVAL, OTHER- (Speclty) 19a. Cr�t:i FUNE i (Or Pe A g a OR ti 20a 3 r r CEMETERY OR CREMATORY 19b• Palm Crematory ICEN AL E ET 20 NAME ..NAME AND ADDRESS OF FACILITY pela.; Mortuary:.;- 20 c.. 744 W, Cheyenne Rd. Las ;Vegas, LOCATION Clly or Town State 19c Las Ve Cheyenne Mevada139129' 1a' To the bes of y kn ledge, death curred'at the time date and place and due to the cau e(s) ated. d .(Sfg u a at Title) 1 r 22a. On the basis of examination and/or Investigation In my opinion death occurred a at, the time,. date and place_ and due to the-cause(s) and manner stated. w .(Signature and Title; DATE SI ED (Mo., Day, Yr) rj 21ti. HOUR OF DEATH 21 2:00 Ali 110 DATE SIGNED (Mo„ Day, Yr.) $o. 2zb.. m HOUR OF DEATH 229 m .4 NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print) 0 i 1d.. 2 .8 PRONOUNCED.DEAD (Mo., Day, Yr.) 22d. ON -PRONOUNCED DEAD (Hour) 22e. AT NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, ATTENDING PHYSICIAN, MEDICAL EXAMINER, OR CORONER). (Type or PrnL) 23a. James Sanchez ND 2650 N. Tenaya' Las Vegas Nevada 89128 s LICENSE NUMBER 23b ''74S REGISTRAR' �n 24a (Signature) t,) G X22 1G.'G RECE IVED BY REGISTRAR Day, Yr) 4b.. E JAN R'� LMDIfAl DEATH DUE TO COMMUNI DISEASE 24c.. "YES❑ NOX` V r25 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (a), (b), AND (c).) `;PART. (a) A P7 rr tp InleivaL onset and death Iri DUE TO, OR AS A CONSEQUENCE OF: v .(b) do d LS? Jq ad ry e£ 1 `Interval between onset and death 7 )720 ;r DUE TO, OR AS A CONSEQUENCE OF: L. 6) J'( `4'7 eel S ci t Interval:between onset. and death f'CC/ PART ,OTHER;SIGNIFICANT CONDITIONS Conditions contributing to death but not resulting in the underly' cause given in Part 1. I I an AUTOPSY (Spe Yes or cify No 26. No WAS CASE R FERR NE CO (Specify 27,. R Yp 'T s IVo ACG;SUICIDE,'HOM:, UNDET., 'ORPENDING :INVEST. (Speci60 DATE OF INJURY (Ms., pay," Yr.) 28b. :'HOUR OF INJURY- 28c. M DESCRIBE:HOW :OCCURRED r 28d. )'INJURY AT WORK "_(Specify Yes orNo) PLACE OF INJURY —At home, farm, street, factory, office,. building, etc. Specify) LOCATION. STREET OR R.F.D. No. =CITY OR TOWN 'STATE_ ;:TYPE. opt 141114 INh ERMANENT..... ILACKINK .:IF DEATH- OCCURRED (5 INSITRRION SEE HANDBOOK' REGARONG.. AMPIETION OF ESIDENCE;ITEMS )NDmONS IF:ANY HIGH' GAVE- RISE TO MEDIATE CAUSE ATINGTHE JDERLYING AUSELAST RTIFIED- TO BE _-A TRUE AND CORRECT COPY OF THE DOCUMENT ON FILE WITH THE REGISTRAR OF ITAL STATISTICS, STATE OF NEVADA" This copy was issued by the Clark County Health District from State 'cert fied.documents as authorized by the State Board of Health pursuant to NRS'440.175 LOCAL FILE NUMBER STATE REGISTRAR VALID WITHOUT. THE D:. SEAL OF THE CLARK HEALTH DISTRICT J I MIL vl I' L v MVM YGrMn IVl Iv l Vf 4 0 29T,Jyf74 DIVISION OF HEALTH TI i AL STATISTICS` CERTh f .,M CLARK COUNTY HEALTH. DISTRICT 625 Shadow Lane P.O. Box .3902' Las Vegas, Nevada 89127 702- 383 122.3 Tax. ID 88-0151573 STATE FILE. NUMBER 251301 DONALD' S.'KWALICK, _MD, M.P.H. Registrar of, VitalStatistics 1QQ4 03660 EXHIBIT "A" PARCEL ONE: Lot Two Hundred Seventy -Five (275) in Block Eight (8) of SOUTH SHORE ESTATES UNIT 5, as shown by map thereof on file in Book 43 of Plats, Page 64, in the Office of the County Recorder of Clark County, Nevada, and as amended by Certificate of Amendment recorded September 25, 1989 in Book 890925, as Document No. 00737 of Official Records, Clark County, Nevada; more commonly known as 8301 Swan Lake Avenue, Las Vegas, Nevada 89128. APN 138 -21- 118 -053. PARCEL TWO: Lot Forty-Three (43) and Lot Seventy -Three (73) in PRATER CANYON ESTATES, UNIT 2, LINCOLN COUNTY WYOMING.