HomeMy WebLinkAbout9775697-1- 6'6/_47
NORTHERN TITLE CO.
PO BOX 856
THAYNE, WY 83127
State of Nevada
County of Clark
s
Wayne T. Wells, being first duly sworn upon His oath, deposes and states as follows:
1.On the January 12, 2013, Janet Lee Smart- Wells passed away, as is
evidenced by the official certificate of death attached hereto and incorporated herein by
this reference.
2. At the time of death Janet Lee Smart- Wells jointly owned certain real property
with me, said real property being located in the County of Lincoln, State of Wyoming,
and more particularly described as follows:
ALL OF LOT 46 OF STAR VALLEY RANCH PLAT 15, LOCATED IN LINCOLN
COUNTY, WYOMING, AS DESCRIBED ON THE OFFICIAL MAP AND PLAT
THEREOF FILED SEPTEMBER 27, 1978 AS INSTRUMENT NO. 514466 IN THE
OFFICE OF THE LINCOLN COUNTY CLERK.
3. Said real property was originally conveyed to WAYNE T. WELLS AND JANET
SMART WELLS, husband and wife as tenants by the entireties, by WAYNE T.
WELLS, dated 9/27/2004, and recorded in the office of the Lincoln County Clerk and Ex-
Officio Register of Deeds on 9/30/2004, in Book 568 at Page 732
4. That the purpose of this Affidavit is to Terminate the Joint Tenancy interest
held by Janet Lee Smart- Wells, at the time of her death, and vest the property solely in
the name of Wayne T. Wells. ''11
Dated this <o 1 020 t L
Subscribed and Sworn to and acknowledged before me this ret l L by
Wayne T. Wells.
Witness my hand and official seal.
Katie Schumacher
Notary Public
State of Nevada
My Commission Expires: 04-25-16
Certificate No: 08- 7614 -1
Affidavit of Survivorship
(,),a
Wayne T ells
Notary Public
977569 7/18/2014 10:20 AM
LINCOLN COUNTY FEES: $15.00
BOOK: 836 PAGE: 307 AFFIDAVIT PAGE
JEANNE WAGNER, LINCOLN COUNTY CLERK
111111111 /111/ 1111 1 /II /1 III /11/ /1 /11 /111111111 /1111 1 /1 /111 /111 /1111 /1! /III /III
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CERTIFICATION AL RECORD
COLORADO D ERA RTI111 ENT4IFT WILIC MEAl.:TH.. AND ENVI RONM.EINIT
i• .1• .1710L1) LIGHT VIE*MATE71114AFt
STATE OF COLORADO 2013000808
C EFITI CATF 0 Ft EATH STATE FILE NUMBER
1. DECEDENTS NAME (F4s
Le WiLLS Temal
4. spate.. SECURITY NUMBER Sa. AGE 5b. UNDER 1 YEAR Sc: UNDERlDAY 6. DAZ Day year
BIRTH.
(Years) Mos Daya Hes Minn
60 n 1I;:. "I; Y. Jui.y 10 1952
ESE;{ 3. DATE OF DEATH,(MonINDay,:year)
B. WAS:DECEDENT:EVER*. 9ePLACE OPDEATH (Check only orie)
IN U.Si.ARIAED FD13CES2 OTHER: 0 Acetated Livi.giNuYalrigHiano' ID Reinke 0 Dedidant's Haeldenaa
•0 Ys 51140. tnmellent EFI)Outpatlent El DOA 11:10therlebecify)
9b. FACILITY NAME (It not Institution.: glue street and number) 86. CITY;TOWN, CR LOCATION OF DEATH 9d. COUNTY OF DEATH
:i St .11a 's •:::HOs ital Medical Canter ..'.:Grand Ji.inctiori: bMisa.:::
10i:4...DECEDENTS USUAL:OCCUPATION (Give kind of Work 10 4.
BUSIN NDUST 1 MARFIAL STA11JS 12 SPOUSE Ir wil, 9 ive e 'd rl
dOne duinost of Working Ma:De use reti
tiFig ree) ."...,r El 1. Meni.d 1 :•'1: Never 'Married Ina/ en ame).,
1
Registered Nurse Nursing DVn
19.e. RESIDENCE -STATE 12b. COUNTY 1136.Cfr117,1N, OF99 /MON ri...sTREETANDNYNIBR
Wyoming 'EV:aX1StI0LI: 48 :East- Ispcn. CrOVe,..Diftye.:•
4:( se. INSIDE CITY IJMITS? 13t. ZIP, CODE 14. WAS DECEDENT OF HISPANIC 15. FIAC American' Ineban,' White, etc. 16. EDUCATION: (Spei: te hestgerte
&Yes% epece Other, Mesican, Puerto Ri Semen (Q-12)
11 .1 533 Ye ON° a2930 sp White 16
AFATHER-
NAIVE (Fuet. fispcIlk INFORMANT NAME and telatle to dpeaased•
Carter Bruce SMART Helen MAULER SMART Brother
20a. METHOD OF DISPOSMON Poiaaation 20b. PLACE OF D151 (Name of calletety cmtnatory, or other 2Bc. LOCATION aty arrow. State
110ThOtspec6) Martin:::.Crematory Grand. Junction, Qo ore o
0
ect
2a. SIGNATUFIE 1 ....DIRECTO OR AC11NC 4991.1 CH 2 NAM EANOADDRESS OF Fe.plyTY
••.Martin':Mortnery 550 North Avenue
224.4
q^!.4
23. 16.15 OF DEATH
55
El AM 1:3 PIA El Milt'
TO BE OMPLETEO 13Y SIGMNG PHYSICIAN
266.Terte teel of rry'ynowiete, ddath occurred at the limaidate
pace, end die to Causr(s)and er as state&
Stenatur0
a Q:;:.k.
236::NAME;ANDA2JLING ADDRESS 0 )E1NE PHYSICIAN
.'.:1tsome„ •A. A.1■14:1st;
A;Nrq
to Immediate
24. DATE ANDTIME PPM
Month
January
uyegse DUE °RASA CONSEOUENc2 OR
Part 2. OTHER SIGNIFICANT CONDITIONS -Ccrlditions coninbutIng to death but not related b cause In Part 1
Grind Jurict.an; 'Italorado 81501
111. 8 I
o MetunT ,171 Accident ElSoicids
1:3 Homicide 0 Pandingtrwestigaion
OUndeterrelned.
12 2013 1:55
•Y
IDTOI3ACCO USE CONTRIBUTETO DEATH
Yes 01 No OProbably Unknown
;20?3
DITEISSI1ED
THIS IS A TRUE"CERTIFIdATION'OP AND FACTSAS
RECORDED IN THIS OFFICE. Do not accept unless prepared on
security paper Avith engraved border.display.ing: the Co1orado state seal
and of the RegiStrar. PENALTY BY LAW, Section 25
'ColOrado gevised Statuts, 1982, if a peison"alters, uses, attempts la..
use or furnishes to another for deceptive use any vital statistics record.
NOTYALID IF PHOTOCOPIED.
22b; FILED (Mon11,•pay,yetu)
MIL
4". Janu 2013
7.BIRTHPLACE (City and State or Foreign County)
P .Ipr sp
15)
25. WAS COSONEFI NOTIFIED?
A' Yes
17,(" don death OCLUired
26. NANIE OF ATTENDING PHYSICIAN IF OTHER THAN SIGNING PHYSICIAN.
31IF FEMA4E;
in Not preprint within Iasi yflar CI Not pregnanl. but ofegnant 43 days to 1
OPisonsof at lime oi &et year before death
rjNol pregnant WI pregnant ivithln 42 days of death rjUoknows If pregnant within the p308 5000.
.A2c:I HE HOVV114.11.1 05C EA
AI4- [7:1 PfX: El mili i 7 N 'P. c)iL;;. viXi.l....e.
gwe ne
11
R
HYMAN
STATE FiEGISTFiAW
Interval betweett coat:tend death
Interval between °neat and death
interval beImo/Ionset and deadt
z I:II
34 AUTOPSY Ir ;iigg;K",7,1"dr"s
.5d`gglie'"
"I :Is"
1 I
6 1 6 3 1 1 1 rPV,
'2 ••"-d1 .iff?
10 kit.,
1
11,
4