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Hickman
LandTtleCo
SINCE 1904
AFFIDAVIT
COURTESY RECORDING
This document is being recorded
solely as a courtesy and
accommodation to the parties
therein. Land Title Co. Hereby
expressly disclaims any
responsibility or liability for
the accuracy content thereof.
I, DIANA D. PIERSON (formerly known as DIANA D. JOHNSON), 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 WYOMING.
That I was well and personally acquainted with MARVIN E. JOHNSON in that certain
Warranty Deed dated DECEMBER 26th, 1996 and recorded DECEMBER 24, 1996 in Book
392, at Page 58, as Filing No. 830908, in the office of the Recorder of LINCOLN County, Utah.
That I know of my own knowledge that MARVIN E. JOHNSON in the said deed and
mentioned in the attached Certified Copy of Certificate of Death was one and the same person.
This affidavit is intended to terminate the JOINT TENANTS of said MARVIN E.
JOHNSON in the following described property:
LEGAL DESCRIPTION
STAR VALLEY RANCH RV PARK PLAT 1 LOT 98, as platted and recorded in the Official
Records of Lincoln County, Wyoming
Tax Roll No. 12-3418-06-2-16-098.00
Dated this ./y day of July 2014 A.D.
977531 7/16/2014 4:49 PM
LINCOLN COUNTY FEES: $18.00 PAGE 1 OF 3
BOOK: 836 PAGE: 259 AFFIDAVIT
JEANNE WAGNER LINCOLN COUNTY CLERK
111111
Diana D. Pierson
(Formerly known as Diana D. Johnson)
VLM
64073
INDIVIDUAL ACKNOWLEDGMENT
STATE OF Wyoming)
SS
County of Lincoln
On the 14 day of July A.D. 2014 personally appeared before me Dona 1). PI erSo
F Ps Diana ID. JO
The signer(s) of the within instrument, who duly acknowledged to me that he /she /they executed
the same.
Commission expires: oa -a Io -a ad`
Residing in: Li„ 606t„4.
a kz_L_
Notary Public
y F.. r+. u nr' b' t. z n a a' r f': �e •:d'Vxs'h:^S
VICKIE MUNSON NOTARY PUBLIC
County of 1 State ot Lincoln
Wyorriing
MY COMMISSION EXPIRES: 26 Dec. 201 16
VLM
's P ame,,:gnclu.10
4 MaWin
A$I ny) t S ,M(gale, L AST
Suff)x
ugene..:;,: Jotxnlson '11/28'/2012:
2,Deatfl
z
use '1 M/)
:(i le.
Age'')_ast Birthday
$2`! 'e
4b. Under .1 Year,
It�onth "s, Days
4c Under -1 D
Hourg Minutes.
5 I S c r Nu e
•C l fd f{C
-,Bi(thdate
'Ida T6,. 1930
8a. Birthplace'(City, town Y)
Ailacoz`tes.; or.Count
Si r i
8b. at$or Fo o g n Cauntiy) t
Wai'r1g on
Sh
9, Decedent s Eduction s'
High School''�G aduate
.e
z`ir
10. Was1'ecedpn }'of: Hispan1 O rigin ?•`(Yes'or NO)lt• es, ec
Y ,aP �y
c AIo:
'f: Decede t' s
1- n s'Ratiet, Y�
Mate?
1�. Was`Decedenri3Jei trhU S:
ii
>''Artned Forces ?No
1 3a ResidenreiyNumber and Street(�.g., 6244 5"' (Include'Apt;', No.) S
8.8$ Hillh rst` Rd.
t
13b. City or fi
r
Riage�ie�a V
r,
1 3cr:Residence =C Urfy
`Cl•srk
Estimate length
9 Months
13 d.TribafReservation'
Nettle( ifappljcable
15: Marital Status atTime ofDeatb 165£tirviving.Spouse's`'br
;Divorced
13e.:Stateor'ForeinCouh
g try-
�1ashirn on
Do(ae`stie Partner's
13f Code 4
9 8 542
Name (G've.n p ri r to
13g Inside:Ciry Limits
El Yes; No „.:1:1'11(1K,':
fast name
e
e)
1 7 :'Usual. Occutation(fticlIdate typg o(work done during,most of workin§ tile. (Do iOT`USERE71REO)
.:Loan Officer
a
18 Kind of Business /Industry (DO t ((se Company
Banking 2
19 Fathers Na(rle':(First,yiddle` Last Suffix)`
;:Eivir C. Johrison
Meili
20: Mothe Lest),'-%.
rs Name Before Firsfrylarriage (First, Middle,
L fli- :q,:l s or.;'
21,.Informant s Name ;.22
dale Fo'restiiar)
r ti h
elaonsip td:Decedent
Daughter
23. Address: 'IA be ;RFD NO. city a stele Zip
ny m r and street o Owns
3141 NW 31 st. Ave'..; Ri 1gOfield 44A: 986.42
2 4: PIac6'of Death, if Deati) Occurred,in'a Hospital: P. ce Death Odcu
I,a af:Death,`if rredSornewhere 0ttjer than a Hospital:
Hos 4 c Faci,:lik
S 5 .Fa iIity. N B m e (If rfo a facilit Iva number street orlocation)''%
2; 112 E;
'Mifl Plain 13Ivd
2fia City Town;,ot Location`of De
Va ncouv er
Z6b: State
WA-
27: Zip Code
9 8661
8: Method p ,e
N! il ?is o §iti n<
7 r
9. Plac of Final;Disposition Name of cemete cremeto ot
ry; ry, other
owe Columbi Crematc/ir -Inc
30' a. 4ocattori- CitylTown;andtState,.•,
"Vancouver, VA
ar)d Comp7ete44iid re of Funeral Fa
sCascadia t 'ematiori Burial Services; Inc:
h 3'03 E 1 fith' Strtaet `Ste A =Vari A 9A
r 1
32 :spate of Disposttiok
i1 2111 7
3 3 Funeral Director Signature; t'- r
mples s)) ^T
rr
>s
'i :;Caau eo ff eatft.(See Instnj bons and exa ^t
34 nter the chain o f events d isea ;es, injur Or o that ditectlycaused the;death, CIO NOT•ent termina.2v s nt such as cardiac arce'st,'respiratory at7est
e ntricular fibrillation' without showing :the etiology,;DO •NOT ABBjtE Kft. A dd additional Iipes if necessary. a
Il1lIMpIATP OiwSE (FloatdisegeeAf lni between O nset& pealtc
.afdittbn resulting in deathp- a. BIEInt..
700` 'Due to (ot 'o
Se ue t all''fs o d as a nsequenad'of) <ilnterval between ORSet 8 Death'
d. n iel. y. f f c n itions;. (f any.Jeadin
Q the: cause listed on line :a Enter the b
e O
Dueto( a n quence ot n
DNbERLYING CAUS disease pr or as a ca se between nset h
9 njUry al g te rva l b e 0 D$at •at-JJlitiated thlevenjs'resulting'in.. �i
A
Due to ora; aconsequertce.of),
35: Other sioni icent conditions contributing to- death(but not re in the urjderlyirlg ca s 9 iven above`
c. Y
36: Ay topsy2?
0YeS< ®`No'
�Intervalbe e
twe n Orlsep8`Death
3 7. Were autopsy findings available to
complete the Cause of. Death?
❑`Yes'••.• >l�
•n
yr=
38•.Mannerof '39.
0 NNankai Hbmicirfe'
Accidertt a Undetermined
Suicide ID Pending 7
1 Date of Injury (Mr trim Yy A• .42.
16/23/2.012:
Iffein`ale
Not pregnant past
0 Pregnantat time iif death
a
lour of Ipjury`(24h s);
'U nknowli';- K...
year fi'Not`Dre reo s before re
n
P. atitwR nt, but a
„n hinA2 dayst deatfs
.t •a Not pregnaht, but•p to regnant 43 days 1 year before death.
Unknown i epregnenfwithin the' ast- ear
P Y ...1.:
43. Place of Injury, te.g., flecedent's home, cbnsliucton site, resfauraiii, wooded are 'a)
:Assi Living` Fa cility'
4 Did tobacco.usp cDntribute'
co
tq death?
0 Yes 'Prob bly
No`� ❑.,t)rlkr5own
44. injury''at WOr$'
`.D >Yes No,, tITink
,'Location.64 fl jury.° Ndmbar Steet 888 ;S Hillhurst Rd API No. i
city or mini ;Ridgefield ;C'ount Clark State WA; ip
sp ecify
=s
s`
ebe ha w y ocu rred
Dscri injur
D ecedent Fell at Assisted Living I aclhty ;i t
i
`ro'tile
47If tnsPdrtatwn Injury', 'specffy:'
njury
;D Dpyerrjoperator, .0 Fedestria
.P rr<
;Passenger se, pi Other (Specify)
:u7
r
a Ceittfymg best: of my_ knowledge death occurred at the time date 8rid`
'ioldoa and due tothe ause(s) and mannerstated
48b. Medi P xa er/ •rOnef• besis'afexaml'hal
I. opini •rrq• t £hdti•
ion, andlor investig`aliop,in my:
and\ lueaotheOause (s)andmn
4 e; :n dp)ace,<
v r i m i k
.i C
an
1 and Addres Certifier. Physic(an, =Medical Eiraminervr Co t4I$1•
Derirus Wickham''MD. Me dicaPExa miiler'PO'B'0 5e
_CAW
a%
7 h' n
t l ant)
a t) 4 2
dy y r ;t
i
o HDU� a[Death
03�
2 Da SI ed fnnnvoo
a
rY�ri
1 f /2`9/2Q12
case referred to M CQrone
Y a N
0ta
1 Name'and Title gf ltteh ing, Physician If other than,C €rtitipr (fyp d.[,j�(
i
Iti�
53 true of Certtfie[
Medical E�caminei
57 Re4rstt r'sreoture
5 License Number 3
c
.i ronerFite N umber
IV ri ,e 821
y
ua
y
Date t7egelQed
6 Was
Amendmepts a
F St t. (t ,it tt S 1 i tti A IS ..••1 s t t t i
;160, G01N 0,F.TRE RAE 0,1RID;;ON IL•.E;V_ll HC EINTER F.OR H.EALT,H S, TATLSTICS C. E. RTIFIEICO -P- I:ES,fu.1.h1`S=
[p oi i o1- o3 f
6 „tIA,.E_I I >L� U11fa(,�AL�
a
I
EPART M'E NkT =C
9c Ie�Jurnber jhr t ertifmate pf Death Stale Fife Nt fibet
rNV�711n�e� :ivii: IYet'i axY:�W4� �C...�:r
it)