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E AFFIDAVIT OF SURVIVORSHIP
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A 976984 6/11/2014 11:1:. ANl
LINCOLN COUNTY FEES: $15.00 PAGE 1 OF 2
BOOK: 833 PAGE: 783 AFFIDAVIT
E
a S'TA'I'E OF WYOMING J EANNE WAGNER, LINCOLN COUNTY CLERK
y cc o COUNTY OF LINCOLN SS !MI I F I N J I111111111I I I III! III II 11 IIII
I- -R
1, Sandra A. Hurst, formerly known as Sandra Amy Conner being of' lawful age and duly sworn
according to law upon my oath and depose and state:
1. That I am of adult age, a resident of Hampton, Virginia, and the Affiant herein.
2. That by virtue of the conveyance which is recorded in the Office of the Clerk for Lincoln County,
Wyoming, located at Kemmerer, Wyoming in Book 103PR on page 62 is recorded a Sheriff's
Deed dated August 21, 1972 which conveys unto Bernice Scott Conner and Elvis Edwin Conner,
husband and wife by the entireties, a Iifc estate and upon their death to Sandra Amy Conner and
Richard Allen Conner, the following property more particularly described, to -wit:
Lots 4, 5 and 6 of Block 4 of the Wyman First Addition to the Town of Cokeville, Lincoln
County, Wyoming.
3. That said Richard Allen Conner died on the 27th day of January, 2014, and a cop:v of the original
certificate of death, certified to an a true and correct by public authority in w hicli the original of
said certificate is a matter of record, is attached hereto as Exhibit "A
4. That by reason of death of said Richard Allen Conner and by reason of stE :te statutes, the
decedents interest and title in said property has terminated and title to the real property conveyed thereby
has vested absolutely in Susan A. Hurst continuously since the death of the said decedent. That the
interests of Berniece Scott Conner and Elvis Edwin Conner have previously been terminaed by Affidavit
Terminating Life Estate recorded in Book 326PR on page 438.
FURTIIER AFFIANT SAYETI -I NOT.
Susan A. Hurst
Th 1 regoing instrument was subscribed and sworn to before me by Susan A. Hurst this j`
day of (N1 2014.
1
'fin hand and official seal.
SHIRLEY WALL NOTARY PUBLIC
C al Si* a4
'Q
'C 5 a Notary Public
Commission Expires:
COMMONWEALTH OF VIRGINIA CERTIFICATE OF DEATH
DEPARTMENT OF HEALTH DIVISION OF VITAL RECORDS RICHMOND
REGISTRATION CERTIFICATE S'E
FOR DIVISION OF AREA NUMBER NUMBER N BER FILE
VITAL RECORDS J 7
DECEDENT 1. FULL NAME =f (first) (middle) (last) 2. SEX male female
OF DECEDENT
Richard Allen Conner
3. DATE OF (mo.) (007) (year) 4, AGE
DEATH IF UNDER 1 YEAR IF UNDER DAY 5. DATE IRTH JF mo (day) (year) 6. AS DECEDENT
T" B EVER W IN U Yes no
January 27, 2014 57 year months I days ours 1 I minutes Apr 4, 1956 ARMED FORCES L,' I Y
PLACE OF 7. NAME OF HOSPITAL OR INSTITUTION OF DEATH 71 none. so state) I Out Pat 8 COUM1 V OF DEATH (if Intlepentlent city, leave blank)
DEATH DOA Emer Rm Inpatient
None I
9. CITY OR TOWN OF DEATH Inside city or town limits? 10. STREET ADDRESS OR RT. NO. CFPLACE OF DEATH
yes no
Hampton Ef 224 Brightwood Avenue
USUAL 11. STATE (OR FOREIGN COUNTRY) OF DECEDENT'S RESIDENCE 12. COUNTY OF DECEDENT'S RESIDENCE of Independent city. leave blank)
RESIDENCE
OF DECEDENT Virginia
13. CITY OR TOWN OF RESIDENCE Inside city or town limits? 14. STREET ADDRESS OR RT. NO OF RESIDENCE ZIP CODE
EA Hampton no
0 224 Brightwood Avenue 23661
PERSONAL 15. NAME OF DECEDENT'S FATHER 16. MAIDEN NAME OF DECEDENTS MOT HER
DATA OF
0
DECEDENT Elvis Edwin Conner Joffre Berniece Scott
17. RACE OF DECEDENT 18. OF HISPANIC ORIGIN? If yes. specify Cuoan, Mexican.
Puerto Rican, etc. 19. EDUCATION (Speedy only m :c mghe;l grade pletetl)
R o White L,] no yes Elements Secontla 3
Elementary/ Secondary (0-12) College (1-4or 5
v
m 20. CITIZEN OF WHAT COUNTRY 21. BIRTHPLACE (state or country) 22. NEVER MARRIED DIVORCED 1 23. IF MAR IED 0 3' /IDOWED. NAME OF SPOUSE
Ll (If divot ;=_d lease Clank)
CI U.S.A. Idaho
Z
Z 2 MARRIED WIDOWED „si
m T 24. SOCIAL SECURITY NUMBER 25. USUAL OR LAST OCCUPATION 26. KIND OF BUSINESS OR INDUSTRY 27. INFOR11 ANT :20 SOURCE OF INFORMATION RELATIONSHIP
o a 520 -56 -0981 rluids Control Eng. Oil Company Sandi Hurst Sister
LL
w CAUSE OF DEATH 28. PART I. Enter the diseases, Injuries. or complications that caused the death. Do not enter the mode of dying, such as cardiac ,pr respiratory arrest, hock., ETW
heart failure. INTERVAL BEEN
w n t List only one cause on each line. NI WR CONSEQUENCE r ONSET AND DEATH
TO IMMEDIATE CAUSE (Final disease or ci 4 1 q r L e
condition resulting in deaths -III' (A) DUE TO A6 A OF) t d
Z PHYSICIAN:
1 qSt (IL C4 )1(
2 E Complete and Sequentially list conditions. If any, leading (8)
Sign medical to immediate cause. Enter UNDERLYING DUE TO (OR AS A CONSEQUENCE OF)
certillcation CAUSE (Disease or injury that initiated
(item 28) and events resulting in death) LAST
return the copy fr)
n 6 to the funeral PART II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I. 28a. AUTOPSY yes no
m 8 director as soon o
t as possible after i= AUTHORIZED BV
8 determination of V
Z cause. E- 28b. IF FEMALE. WAS THERE A PREGNANCY 280. IF EXTERNAL CAUSE. IT WAS
F
1- cc IN PAST 3 MONTHS? 28tl. DESCRIBE HOW INJURY RELATING C DEA-! OCCURRED
0 n PFIAPY 0 w CONTRIBUTING 0
a NOTE: It U C
TO CAUSE OF DEATH
"Pending' must yes no El unknown
be Indicated, so -7( 28e. TIME OF INJURY (mo.) (day) (year) 28f. INJURY OCCURRED 28g. PLACE OF INJURY ihome, farm, 17 n I, or town
state In pad 1 0 factory, street, office bldg„ etc.) 1 y (county) (state)
and notify A.M. whsle not while
I
registrar of final at work at work
decision as soon 281.
as possible. To the best of my knowledge. death occurred at
(a m.) (p. n.■ on the date and place and from the cause(s) stated.
{1 C TE SIC. D
ACTUAL GNATURE fi r'- `J�•r'
SI -J -1-• 3
NAME OF ATTENDI PHYSICIAN Type or RAP IA ^DRES 0 AT PH Y ICIA. J Y
cc l E L ru'clr .0 C trl'Set.kk ticaixt (A-
FUNERAL 29. BURIAL REMOVAL CREMATION 30. PLACE (name of cemetery or crematory) (city or county) (State)
DIRECTOR RREMOV,1a�`T
E C. C rea ti ve Cremation Resources
E] Hampton, VA
31. (signature of funeral director or_per50P legally filing Ines cert NAME OF FUNERAL Herceuse F TOerat S Cremation Tradition:
l ADDR Hampton, VA 23666
FUNERAL SERy416 LICENSk- L- N&YT-OR KIN( f" �r
REGISTRAR 32. slg -Cure of registrar 4ATE RECORD
RES ED FOR 7
N REGISTRAR'S USE
This is to certify that this is a true and correct rep K axa•o original record filed with the Hampton Department of Health, .Hart_, p 9 r)
Date issued: S r O A C i i./,G P.)
Registrar u •De "4 P+++'.. "e.,,
Seal
DO NOT ACCEPT UNLESS IT BEARS THE IMPh�-Eg E j THE
HAMPTON DEPARTMENT OF HEALTH CLEARLY AFFIXED.
Section 32.1 -27, Code of Virginia, as Amended