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Home My WebLink About976986 J -o 976986 6/11/2014 11:13 AM u LINCOLN COUNTY FEES: $15.00 PAGE 1 OF 2 o c BOOK: 833 PAGE: 786 AFFIDAVIT ru JEANNE WAGNER, LINCOLN COUNTY CLERK r 1 III I 4 1 HHW III1 11 11 1 IN III I I TI 11I11 111 1 IN HI 0 o AFFIDAVIT OF SURVIVORSHIP c t o -0 o STATE OF WYOMING H► SS. COUNTY OF LINCOLN I, Sandra A. Ilurst, formerly known as Sandra Amy Bryant 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 I Iampton, Virginia, and the Affiant herein. 2. That by virtue of the conveyance which is recorded in the Office of the Clerk ror Lincoln County, Wyoming, located at Kemmerer, Wyoming in Book 225PR on page 119 is recorded a Warranty Deed dated July 10, 1984 which conveys unto Richard Allen Conner, Joffer Bernice Scott Conner and Sandra Amy Bryant as joint tenants with full rights of survivorship, the fol owing property more particularly described, to -wit: The W1/4NE1/4 and E1/2NW1/4, Section 8, T25N RI18W, of the 6` P.M., Lincoln County, Wyoming, described under the Resurvey as Tract 74, containing 159.57 acres, And Lots 18, 19 and 32 of Section 8 and Lots 3, 4, 5, 6, 7, 11, 12 13 and SE' /4NW!%, of Section 9, T25N RI 18W of the 6 111 P.M., Lincoln County, Wyoming, containing 262.43 acres. 3. That said Richard Allen Conner died on the 27th day of January, 2014, and a copy of the original certificate of death, certified to an a true and correct by public authority in which 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 state 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 interest of Joffer Berniece Conner was terminated by Affidavit Terminating Joint Tenancy in Book 326PR on page 435. FURTHER AFFIANT SAYETH NOT. Susan A. Hurst L The foregoi 'Instrument was subscribed and sworn to before me by Sandra A. Hurst this day of 2014. swizEY NWAy c' official seal. 1• Notary Public Commission xpires: a 5 1 f3 COMMONWEALTH OF VIRGINIA CERTIFICATE CF DEATH DEPARTMENT OF HEALTH DIVISION OF VITAL RECORDS R CHMOND REGISTRATION CERTIFICATE STATE FILE FOR DIVISION OF AREA NUMBER i j NUMBER NUMEIER VITAL RECORDS DECEDENT 1. FULL NAME (Ilrst Nast) OF DECEDENT (middle) 2. SEX male female Richard Allen Conner 3. DATE OF (mo.) (day) (year) 4. AGE DEATH IF UNDER 1 YEAR I IF UNDER 1 DAY 5. DAT 0= Imo (day) (year) 6. WAS DECEDENT January 27, 2014 57 mor090 T'- days hours rro �B =T H 4 1 956 A ARMED F RM R. ORCESo 0 no I ars p I-Y L1' ye PLACE OF 7. NAME OF HOSPITAL OR INSTITUTION OF DEATH Of none, so state) Out Pat, 8. COUNT" OF D _4TH (if Independent city, leave blank) DEATH DOA Emer Rm Inpatient None 9. CITY OR TOWN OF DEATH Inside city or town Ilmlts? 10. STREET ADDRESS OR RT. NC. TF PLACE OF DEATH yes no Hampton 224 Brightwood Avenue USUAL 11, STATE (OR FOREIGN COUNTRY) OF DECEDENT'S RESIDENCE 12. COUNTY OF DECEDENT'S RESIDENCE .f Independent city. leave blank) RESIDENCE OF DECEDENT Virginia 13. CITY OR TOWN OF RESIDENCE inside city or town limits? 14. STREET ADDRESS OR RT. NC. C F RES DENCE t ZIP CODE fl Hampton yes 0 224 Brightwood Avenue 23661 PERSONAL 15. NAME OF DECEDENT'S FATHER 16. MAIDEN NAME OF DECEDENT'F, MOTH DATA OF DECEDENT Elvis Edwin Conner Joffre Berniece Scott A 17, RACE OF DECEDENT 18. OF HISPANIC ORIGIN? It yes. specify Cuban. Mexican. 19. EDUCATION (Specify only highe.s�. grade Puerto Rican, etc. �-7[ u c White I� no yes 3 4 Elementary/Secondary py 10-12) College or g c 20. CITIZEN OF WHAT COUNTRY 21. BIRTHPLACE (state or country) 22 NEVER MARRIED DIVORCED I_I 23. IF MAPR _D OR Vd. DOWED, NAME OF SPOUSE a E U. S A. Idaho L-I (if dlvorc leave hank) Z MARRIED WIDOWED E 3 T 2 SOCIAL SECURITY NUMBER 25. USUAL OR LAST OCCUPATION 26. KIND OF BUSINESS OR INDUSTRY 27. INFORM? NT CR SOURCE OF INFORMATION RELATIONSHIP o L 520 56 0981 rluids Control Eng. Oil Company Sandi HL.rst Sister LL 0 28. PART I. Enter the diseases, Injuries, or complications that caused the death. Do not enter the mode of dying, such as cardiacpr respiratory arrest, sock, or heart failure. INTERVAL BETWEEN Q G CAUSE OF DEATH List only one cause on each line. ONSET AND DEATH w n rr T m TO I MMEDIATE CAUSE (Final diseas or !AI CiG /'f� r i 1 ✓1 �(v c t a n a co ndition resul In tl eath) DUE TO' 3 31 w 73 PHYSICIAN: AS A CONSEQUENCE OF at n Complete and Sequentially list conditions, if any. leading (B) q9 f1L C4 n(t7 sign medical to immediate cause. Enter UNDERLYING DUE TO 106 AS A CONSEQUENCE OF): certification CAUSE (Disease or in(ury that initiated (item 28) and events resulting in death) LAST return the copy 101 a 8 to the funeral z PART II. Other significant conditions contributing to death but not resulting In the underlying cause given in Part I. 28a. AUTOPSY? yes no c director as soon O f as possible after F AUTHORIZED BV: F n determination of U Z cause. LL a i 28b. IF FEMALE. WAS THERE A PREGNANCY 28c. IF EXTERNAL CAUSE, IT WAS 289. DESCRIBE HOW INJURY RELATING T DEATi OCCURRED H IN PAST 3 MONTHS S ti PRIMARY a CONTRIBUTING a F NOTE: if 0 yes no unknown El TG CausE OF DEATH "Pending" m00t be Indicated, so U 28e. TIME OF INJURY Imo.) (day) (year( 28f. INJURY OCCURRED 28g. PLACE OF INJUPY (home. farm. 2Bh. :i or town) (county) (state) state in part 1 p factory, street, office bldg., etc.) and notify w A.M. while CI not whsle registrar of final P.M. at work at work decision as soon 281. as possible. To the best of my knowledge. death occurred at (a (p.m.; en the date and place and Earn the cause(s) stated. ACTUAL -IDAIE D. SIGNATURE j I 1 j j j I/ NAME OF ATTENDI PHYSICIAN Type or Pri 11 I J y( I A DRES O .4T' ENDING PHY ICI d FUNERAL 29. BURIAL REMOVAL CREMATION 30. PLACE (name of cemetery or crematory, (city or county) (state) DIRECTOR R EMOVAL L ETC. Creative Cremation Re sources Hampton, VA 31. (Signature of funeral director or- perso0 legally Ming this ,certificate). NAME OF FUNERAL .derceuse cremation Traaltlonl HOME AND ADDRESS: Hampton, VA 23666 FUNERAL SER r LICENSb •..NEXT OF KIN Jait, -C i 4- a REGISTRAR 32. ig .ture of registrar AT E L `FI LED R ECORD 5 RES; ED FOR N REGISTRAR'S USE 5) This is to certify that this is a true and correct repr::o i ori record filed with the Hampton Department of Health, Ha ton, Vir *i gi. ,7 Date issued: .k,'t Registrar 0 a y+ u I Seal DO NOT ACCEPT UNLESS IT BEARS THE IMP A 'bF TI- E HAMPTON DEPARTMENT OF HEALTH CLEARLY %'PP1 1 'X Section 32.1 -27, Code of Virginia, as Amended