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I, Mel Hollabaugh, being of lawful age and duly sworn according to law, upon
my oath, depose and state:
That under the date of June 30, 1993, for valuable consideration, Battlefield, Inc.,
a Wyoming corporation, by deed of that date, which deed was duly filed of record in the
Office of the Lincoln County Clerk, on June 3o, 1993, in Book 331PR, Page 429, conveyed
to Mel Betty Hollabaugh, the following described land, in the County of Lincoln, State
of Wyoming, to -wit:
Lot 70, Unit C -2, Commissary Ranch Subdivision, Lincoln County,
Wyoming
That by reason of said conveyance aforesaid, the said Mel Betty Hollabaugh,
husband and wife, became the owners of said real property, and the title thereto vested
in them continuously from the date of said conveyance, to the date of death of Betty
Hollabaugh, also known as Betty Mae Marie Hollabaugh, on the 25th day of November,
2013. That by reason of and upon the death of Betty Hollabaugh, also known as Betty
Mae Marie Hollabaugh, title in the above described real property vested in Mel
Hollabaugh.
Affiant avers and certifies that Betty Hollabaugh, also known as Betty Mae Marie
Hollabaugh, is the identical party named with Mel Hollabaugh in the aforementioned
deed, whose death terminated her interest, title and estate in said real property; and
Affiant attaches hereto, and makes a part of this affidavit, a copy of the Official
Certificate of Death of said decedent, duly certified by the public authority in which said
death certificate is a matter of record.
4
oo a00000000 ;y_
Dated this 8 day of
State of I Qp .t!
County of U� 1D
Subscribed and sworn to before me, a notary public in and for said County and
State, by Mel Hollabaugh this 13 day of
WITNESS my hand and official seal.
Affidavit of Survivorship
ss.
sion Expires• tFP___ 1
977360 7/8/2014 11:16 AM
LINCOLN COUNTY FEES: $15.00 PAGE 1 OF 2
BOOK: 835 PAGE: 751 AFFIDAVIT
JEANNE WAGNER LINCOLN COUNTY CLERK
111111111
101 IIII II II I I II
11 11111111111
2014.
1 Hollabaugh
Notary Public
1101 IIIIIIIII
itiDEQEDENTISIEgAUdNAkig(FIRST, MIDDLE, LAST)
''''kl,(1_1 _..t. I'd
1!,•.ETTY,-,,MAEMARIEHOLLABAUGH I
S
2. AKA'S (IF ANY) 1 t')
3 )PATE, OPPENTM
4SEX,'''''
FEMALES
5. SOCIAL SECURITY NUM,BER:
6. DATEOF BIRTH
07/23/1948
7. AGE
6
UNDER:1YEAR,
DER 1 DAY-1.
8. MONTHS
9: D/y1S,!Vi','"'
10.
111VINLITES:.'
12:PA
lEliINFATiE
-HOSPITAL:
E:R:/OUTPATIENT OblEADOKI ARRIVAL....
13. PLACE OF DEATH -OTHER THAN
'NURSING HOME OR 1--J.
:b LONG TERM CARE' FACILITY
OSPITAL:'
l,, tH,...'
LJ nESIDENCE HOSPICE Ft‘CILIT T: L_Ju IER
14i IF NoTAFAD0J
-..:::::,fit-frp.e.-...,..;-::::'..,...-J.
NUMAREGIONAL MED L CENTER
15. CITY, TOWN& ZIP CODE ORLOCATION.OFDEA TH:
NUMA85364
16.CRUTDEAT H,
..11,0,191 (cAry..,.i■No., 09 FOREIGN COUNTRY)
t,.
1tiMCd bicifNEL.4AS. -kf
18. MARITAL STAT
DEATH:-
MAkRIED
i v.\ i
3 AT TIME OF
19. NAME OF SURVIVING SPOUSE (MAIDENMAMErIFWI E
.1'..,1-'11.-"'' fli■';■:i.'
MELVIN' HOLLABAUGH.7:)1V2;•
A0:112c1:15NIPS,U,p,#y,13PIRENCE STREET ADDRESS:
12556',435TH•i0b; •'•1 1
21. CITY AND COUNTY:
YUMA, YUMA
22. STATE
ARIZONA,.... 2.;
2S,21pCOOE:
'1,
24.EVER
25MASDEDEDENTtor HISPANIC ORIGIN?
rEEV;NO170ANISR1-IPPANIC OR LATINO
jj11AEXICAAL MEXICAN AMERICAN, CHICANO
=0")
;11: -Y:E r k,"Cd-BANg FIICAN
EiOffikik(SBECI
26. DECEDENT'S RACE(S):r
BLACKAgRICAF.F 181 WHITE 0 bt-IER ASIAN (SPEC (SPEC F.
0 AMERICAN--,------,
27.v:AMERICAN INDIAN OWALMNA NATly:
.SFECIFY_UP TO 41:F1113ESI''...4 '..I.::.j. 2k
..,:-17•FIIMA....R,9.;3„..N:,.4.,,..;„°C..,it.„947FI.,:,l,„,,17:7?ft V
0 NATIVE HAWAIIAN
0 ASIAN1NDIAN 0 OTHER PACIFIC ISLANDER (SPEOIFY)
ApoitiolveanitiE:4'!.-7-
JAP,ANESE
NIAN OR 'CHAMORRO OTHER (SPECIFY) 't
ADDITIONAL TFile
17‘ UNKNOWN:
941
g81)C ,N,e`A, ,.:16 .1 ■:0, s,:.,.
OMEMAKER%.
0 VIETNAMESE ii'
SAMOAN 4 i'-
ci, AMERICAN INDIAN'OTALASKAI_N,ATIVE
A Ag.14■■ t'AW 1,1'
p ii00. NI
WFATEFESINAME;(FIRSX,r.MID.OLE, LAST) ..-1
,1
,),7
0MPTHER'eNAKEOT,ISTi,MIDDLE, LASTNAME PRIOR TO Fipa 0
,f-...r
L ORNA SEARI_E?.c' ,,.1.nild,h 1.; •y11......
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ORTUARY8,CREMATORY551W 6TH STREETqYUMA,AZ•>-`
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bARRENSMTTICE FUNERAL.DIRECTOR'/,':
36
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3nmETnoD(s)OF,DISPOSITION:...
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t14EMAT
38.1\1MEAND LOCATION OF Ist DITOSITIONfACIpTIJA
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YUMA MOK tUARY'& CREMATORY, YUMA;'tAFFIZON )y
3 NAMANDIAOCATIONOF2ndIS17031TIONFACIL11
NONE-..; .1
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CONSEWENCEOF::.
42.'(30.'',',:'
ACUTE MYOCARDIAL INFARCTIbw._
43. APpROXIMATEINT#IVM;%:,
UNKNOWNP
PUEiT0-013AS2k-
coNsEpugNpE•OF:!
z A44..T-.L. „i• 4,:f:',-..=_3--:
44. q.,,,..
45.. AEFFIOXIMATE)NTEtty/11::.„'” 'i%;,'..
DUKOrOfrASK-Y
OONSEOUENCEVE:
46::-D '1
47APPROXIMAT,E3NTERVAVI 12
VcAtliE
450,pEATI-1iii;i■
N;1S.y,NpEFILmtNc GIVEN ABCVE:
s "1 1' 11 ,1',r
49: INJURY?
NO
50:INJURYATWORK17
y-
NO
51.MANNEI1, OF DEA, TH
'"ae .jtriN N1,1k,11;',V'''r
NATURAL
57
411T'-`14 I
qr;160
53. WAS AN AUTOPSY PERFOPMED?
NO s.
54. WEREAUTORSYFINDINGSAVAILABLET017, 1
-t.".!": 4 1 ...::•.•;i 4,:':;01•;.'.;•..;.
'!»'.5;: VS NO,M
AmoNlyi;'::' 1
ter Assistant To the best of my
-know [edge, the cause(s) and manner stated.
17,1*(6416iintiierifiibal L Authority On the basis of examination,
,aldfor MI/Opinion; death occurred at the time date and place, and
duelothelcause(s)andmanner
55. NAME OF PERSON COMpLETINGcAusEofoE,,,, TH,
MALLAPPA NEELAPPA, M.D.
50;DATEc03T/FIED;p
f1
39MATiREGISTEREDa
'..-12/15kbi3' 1 -.:9',
57ACE1FrrIFIEITS:A1 -1,:
2275 YUMA, AZ 85364-6258
58". NAME OF REGISTRAR:
ANA P TRIGUEROS Ai.M. ,.::r•
0
A ri zo n
De partmept of
1H ea Ith Services
CERTIFICATION OF VITAL RECORD
ANY ALTERATION OR ERASURE VOIDS THIS DOCUMENT
:STATE OF ARIZONA
DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS.
CERTIFICATE OF DEATH
This is a true certification of the on file with the OFFICE OF VITAL RECORDS,
ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA
R6ised 12/2012.
This copy not valid unless,p1 on a form displaying the State Seal and impressed AIM
SISTANT/STATE