HomeMy WebLinkAbout977707STATE OF WYOMING
COUNTY OF LINCOLN
ss.
I, ROSIE LOWHAM, being of legal age and first duly sworn, deposes and says as follows:
1. That the following decedents:
a. Lena Borino;
b. Albert Borino;
c. Joe Borino;
d. Lucille Wainwright;
e. Margaret Wilkes; and
f. Annie Roberts.
AFFIDAVIT OF SURVIVORSHIP
mentioned in the attached certified copies of the certificates of death, are the same persons
named as parties in that certain Quitclaim Deed dated October 12, 1989, executed by Lena
Borino, a single woman and Albert Borino, a single man to Lena Borino, a single woman,
Albert Borino, a single man, Joe Borino, a married man, Lucille Wainwright, a married
woman, Margaret Wilkes, a single woman, Ann Roberts, a married woman, and Rosie
Lowham, a single woman as joint tenants with the right of survivorship, recorded as
Receiving No. 708992, on October 12, 1989, in Book 278PR at Pages 585 and 586, of the
Official Records of Lincoln County, State of Wyoming, concerning the real property situated
in the County of Lincoln, State of Wyoming and described as follows:
Parcel No. 119 of the Town of Diamondville, Wyoming, as shown
upon the plat thereof dated August 31, 1942, containing 7500 square
feet, more or less, together with all improvements and appurtenances
thereon situated or in anywise appertaining thereunto.
Subject, however, to all reservations, restrictions, exceptions,
easements and rights -of -way of record.
2. That the certified copies of the certificates of death indicates the following:
a. Lena Borino died on October 20, 2013 in Kemmerer, Lincoln County, Wyoming;
b. Albert Borino died on October 1, 1996 in Evanston, Uinta County, Wyoming;
c. Joe Borino died on July 13, 2006 in Kemmerer, Lincoln County, Wyoming;
d. Lucille Wainwright died on December 31, 2007 in Kemmerer, Lincoln County,
Wyoming;
e. Margaret Borino Wilkes died on February 13, 2010 in Lehi, Utah County, Utah; and
f. Annie Roberts died on July 24, 2005 in Salt Lake City, Salt Lake County, Utah.
3. That I am the same Rosie Lowham mentioned in the above referenced Quitclaim Deed and
the sole survivor and thereby am a person interested in the effective property or the title
977707 7/25/2014 2:03 PM
LINCOLN COUNTY FEES: $33.00 PAGE 1 OF 8
BOOK: 836 PAGE: 554 AFFIDAVIT
JEANNE WAGNER LINCOLN COUNTY CLERK
1!IIlJI1111111 IIII IIIIII IIIII II111111 IIIII III 11111IIIII IIIII 1111111111111111
thereto and pursuant to 2 -9 -102 W.S. (1980) hereby make the deaths a matter of record and
certify that upon the deaths of Lena Borino, Albert Borino, Joe Borino, Lucille Wainwright,
Margaret Wilkes and Ann Roberts, their previous estate in the property was terminated and
vested solely to me.
Dated this E _2 day of July, 2014.
STATE OF WYOMING
ss.
COUNTY OF LINCOLN
DEBRA A. HANSEN NOTARY PUBLIC
COUNTY Of
LRCOLN
IN COMMISSION EXPIRES
STATE OF
WYOMING
5
ROSIE LOWHANI
This Affidavit of Survivorship was subscribed and sworn to before me by Rosie Lowham,
this .,15 Ih day of July, 2014.
/V a'\'2 1
NOTARY PUBLIC
My Commission Expires: 3p4/// 5
2
The immediafe cause is listed :on the first line followed by any underlying c4useS.
(a)-Multi.Organ Failure
Dehydration
(c):Mainutrijion
COPD, Anertia, HTK Hypothyroidism
OtherSignifi�nt
lVlanner 'Of Deth:'' Natural Death
.0 ...i, .1:
T
'Nerne: George Krell, M.D.
'Address:
'i:::..
Filed: November 14; 2013
Decedent:
i.Getider:
pate of Birth:
ate .and Pla o e.a
Date of Death bdtobei‘20, 2613
Cif Death Kemmerer
StiOth LinC•Oln:Nureing„CenteritIpflsocs
dditional Decedent Infermation:
RiaCe.of Birth: Glencoe, Wyoming
Marital ,Status 'Never Married'.
,Arnied,Forces:
,l'AVOrne of Father:
Name Of Mather:
2.1n
PacilitY:
4{4,
ff z, r t fretgl .4.45n rhOlArigN.V
1 061 11/.1 •41P
I
d CEO,' ,CATI „AL RE CORP'
reo!o'
ethod of Disposition:
lece of Disposition:
:Uneral Name orfaailibj:
733687
TA
Lena. Borino
Fernale
April 14, 1915:
No
Joseph Bcifinos
Maggie Makello
Rosie J. Lowham
'Burial/
South Lincoln Cemetery, Kemmerer, Wyoming
Ball Family ChapolanSton;::.WyOming
hysiCian
DEPARTMENT OF HEALTH
CERTIFI
.State File Number:
li me �fb�atlt
PQ Box 39o,, Kemmerer, Wyorning, 83101.:
This is a true certification of the document on file in the office of Vital.
Statistics Cheyenne Wyoming,
Fri day November DATE ISSUED a or..
popy,is notyalid unless prepared oh paper widi an engraved holden
Relationship:
poOial
Age at the of Death:
COuntY of Death:
eitOir,g+
2013-003443
98 years
Lthcciin
SiSter
12:28 (Actual)
James Mcddde
Deputy State Registrar
5Mu i
E C 42 1;•':`, ,,:f ,4 :1 Pil s r Or''.,
10,510
f
00.
P,0
4
TYPE
OR PRINT
N'
PERMANENT
BLACK
•'INK
',FOR
;'INSTRUC11ONS
SEE
HANDBOOK
4. SOCIAL SECURITY NUMBER
70. PLACE OF DEATH (Check only one)
I 13a. RESIDENCE STATE
Wyoming
130. INSIDE CITY S?
190. INFORMANT -NAME (Type or RiAI)
190. MAIMNG ADDRESS
20a. Burial, Cremation, Removal
from Stale. Other (Specify)
Burial
VR 2 -89
4/94 15M
1. DECEDENT -NAME FIRST MIDDLE
HOSPITAL, DTHER:
LW Inpatient ER /Outpatient DOA
71e. FACILITY NAME (fl not Inslludon, give street and nunber)
12a.,USUAL OCCUPATION :(Give• kind of work done duing. most.
•of working Ille, even g retired)
Operator
B. STATE OF BIRTH (1/ nor In USA., name country)
11. WAS DECEDENT EVER IN US. ARMED FORCES?
(Specify yes or no)
L t` l0 !f_ I 1 Y il s tE/:!! R j"a a i
�y CE OF VITAL RECORD
:ti �s`nYC• ..tae K `G-J •�Cf n7.i i P_SY" -53. .s .rn =STi
a• a: 1, 1; 1. 1. 1. 1}• Ya}• 1. 1k7; k1•a3,1,19•11•1.1•a;t•a•!•l;a•a• lye• art}• kk ka•(k lA t}• a•; Yl•!; a¢• 1; SAS• a• aa• 1}• 1. 1. 1; 1A 1; a• a• 1• J1• ak kl, 1. 1• a• a• YVa• 1• kka jN I: kl• 1V•{• 1•a•l•A1;1,1,4,1•Y!•4,1,t•{,kkk
LOCAL FILE NUMBER
Albert
Evanston Regional Hospital
Wyoming
No
(Specify yes or no)•
Yes
17. FATHERS NAME First
Joseph
Lena Borino
STATE OF WYOMING
79
Middle
STREET 013 RF.D. NUMBER
DEPARTMENT OF HEALTH
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
5a. AGE -Lest Birthday
(Years)
73
NSTOC Yes 0 (Spedly)
Months
Nursing Home Residence Other (Sped/0
9. MARRIED. NEVER MARRIEO,
WIDOWED, DIVORCED (Spedly)
Divorced
13b. COUNTY 13c. CITY, TOWN 0R LOCATION''
Uinta Evanston-
14. WAS DECEDENT OF HISPANIC.ORIGIN?
(Specify no or yes If yes, specily
Cuban, Mexican, Puerto Rican, Etc)
Last
Borino
CITY OR TOWN 'STATE
Diamondville.. Wyoming 83116
20b. DATE (Ma, Day, Yr.) 2Oo CEMETERY OR CREMATORY -NAME 20d. LOCATION:; CITY OR TOWN STATE
5, 1996 Kemmerer Cemetery Kemmerer, .Wyoming
Number 210 ADDRESS OF FACI
21a FUNERAL SERVICE LICENSEE Or Number 21b NAME OF.FACI
IJT.Y LITY
As Syc� (Slgrease)
22a To t best of my nowle
3 Crandall Funeral Home 28
to the catnaps) emcee. Mai at tne,nme,;oate,ana,
Kemmerer, yoming
Piece and pus to 111e mtuelll;nauc
(Stockily and 7100) 8rd ..(S/gnatu0 and 1111o)
226. DATE SIGNED (Mo., Day, Yr.) 22c HOUR OF DEATH 1 '.23b DATE SIGNED (Mc Day, YU 23c HOUR OF DEATH
10 -2..- 9(p 7.:46
St, 23d. PRONOUNCED DEAD (Afo Day, &J
1 0
P.O. 'Box 94
26e. REGISTRAR
(Signature)
PART 1. Enter the diseases„
e. or reepirotory arrest
IMMEDIATE CAUSE (Final
disease or condition
mauitin0 an death) 09
Accident
Suicide
Homicide
22d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type a P1M)
24. NAME AND ADDRESS OF CERTIFIER. (PHYSICIAN. OR CORONER)(Type a PriV
Thomas Simon M.D 150 D
Sequentially list conditions,
0 any, leading to Immediate
00000. Enter UNDERLYING
CAUSE (Disease w i0)ury
that initiated events
resulting In death) LAST
29. MANNER
OF DEATH
Natural ,DPending
!me!medication Could not be
Determined
09973
b.
c
DATE ISSUED
LAST
Rorinn
5b. UNDER 1 YEAR
Days
Deputy
s, or 0omplicalions that caused death. Do: not enter the mode 01 dying, such oe cardiac
w
ck, or heart failure. Ust only e cause on each fine.
TO (OR AS A CONSEQUENCE OFI:
DUE TO (OR AS A CONSEQUENCE OF):
DUE TO (OR AS A CONSEQUENCE OF):
PART IL OTHER SIGNIFICANT CONDITIONS-Conditions contributing to death but not related to cause given In P.
30a. DATE OF INJURY
rMomh, Day Yes)
306. IME OF
'INJURY
M
30e. PLACE OF INJURY-At home, farm, etreel, factor
office hdtling, etc (Spot fy
7c CITY, TOWN, OR LOCATION OF DEATH
Evanston'
10. SURVIVING SPOUSE; ((I offe, madden name)
15. RACE American Indian,
Elock, White, Etc.
,(Specl
White'
1B. MOTHER'S NAME; Fret
This is a true and exact reproduction of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.
Hours
Se. UND
30c. INJURY AT WORK?
(Specify yes or no)
2.0E6
Male
R 1 DAY
Minutes
13d.- STREET AND NUMBER
475 YellowrrPok RH_
Maggie
12b. KIND OFBUSINESS OR INDUSTRY
Standard Oil Plant
16. DECEDENT'S EDUCATION
'(Speolly N ate's( grede cartpleled)
Elementary/Secondary ?(0.12) College (1 -4 or 5
12•:
19b. RELATIONSHIP TO DECEDENT
Sister
STATE FILE NUMBER
3. DATE OF DEATH (Mo. Day, Yr.)
October 1, 1996
B. DATE OF BIRTH (Me, Day, Yr.)
March 9, 1923
21P CODE
October '3, 1996
7d. COUNTY OF DEATH
Uinta
Middle Malden Surname
Marchello
Evanston, Wyoming 82930
25b. DATE RECEIVED BY REGISTRAR (Ma, Day, Yil
23e. PRONOUNCED DEAD (How)
M
'Apptoelmate
Inlorvol Between
Onset and Death.
.2 1
27. AUTOPSY (Spedly 28. WAS CASE REFERRED TO CORONER
yes or no) (Spedly yas no)
No No
30d. DESCRIBE HOW INJURY OCCURRED
301. LOCATION (Street and Number or Rural Route Number, City or Tam, State)
Lucinda McCaffrey
Deputy State Registrar
This copy 1s not valid unless prepared On paper with an engraved border displaying the date, seal and signature' of the Deputy State Registrar.
Taw
:'br': i:' ri': r.': i:' ciasisi• isisisiti: isisisisisisisisisisisisisisisisisisisisisisisisisisisisisi: i. isisisisisisisisisisisisisiriasisisisisisisisisisisisisisisisisisisisisisisisisisisisisisisisisisisisisiri: i• iisitiasisisisisisisiriasi :i:i:i:i:iti:i:i:i:i:i:i:i:i:i.
4 00,
wiway wwirommacrwrifeloot„,x1,40,\61wskistwei i
SSP
cERTIFIcATio ITAL Rfc0RD--
STAT 0
CERTIFICATE OF:DEATH
State File Number:
Wife
Lincein
James McB4de
Deputy State Register
2006-002118
Vgir
-Decederit:
rider:
bate of Birth:
ate and Place of De
liDate,of Death:
CityofDeath:
4:Oatien:
dditional Decedent
ace. of Birth:
esidence:
Status:
Rafts of Fathei
an)e Mether:
InfOrrnant:
:r4+
ethod �f DispoSitiori:
ace of Disposition:
unerel:Herne ori,Fac
Significant„
'Manner of Death:
Certifier:
•Name:
Addreas:
'Date
e
.ath:.
0154
Jee. Borino
Male
June 18, 1921
July 13, .2006
Kemmerer
413 eappiilre 'Street
Inforrnatien:
.Diartiondville, Wyoming
!Kemmerer, Wyoming
Married -tarrie"ern Marlin
Yes
Giliseppi Benno
Maggie M: Marchello
-Carrie Fern Borino
ility:
Burial
Kemmerer Cemetery, Kemmerer, Wyoming
USerof Death:::
The irninediate cause is listegtbn the first line folk:Aft/ed. ariy underlying causeS.
i(a) Soft Tissue S'arcoma
BaL Family ahapei; 8
PhysiCian
Chris Krell, M.D.
711 Onyx; Kemmerer, WY
JOly 19, 2b08
s
Thls is a true certification of the document on file in the office of Vital
ptatispcs Services,.cheyenn.9, Wyoming
s
4 DATEISSUED: Monday, July 21,\2014
notyalid oppaper. wjuran
So61a.l.SecuritY
Age atthe Time of Death:
Count Death:
Time Of Depth
85 years
A
1
;411
fgh
Ir w k•Par,A,,l' 405
ptft, 4 N
CERTIFICATION OF VITA RECORD
cert ificitiOn of the dom ent on file in the office of Vital
i:
Sery ices, Cheyenne, Wyoming
4- _DATE
copy is, not valid unless preparccro7'paper with an-engravccl border.
Decedent State File Number 2007;063934
Lucille Wainwright
Social SecuntyNtIrn.her.;.
at&of.Bitth:;' M a y s Age at the Time Of. Death 89 years
atoand of-Death:
atk of Death 0.0Cember 2007 of Death Lincoln
itY..:OfDea.t11:
k
1••■••.. TO,V.,11a1c:73 I CA
virliAtale
'1 4
4
Death:
ity
rmed Services:
ouse's Narne:
�dustry/Business:
gidence,
ofler's Name:
.acil,ity %or)Add ress:
CEDENT INFORMATION
teof Feb 13, 2010
of eath: Lehi
Barry E. 'mangle, State Registrar
Office of Vital Statistics
4 S+� t'IJ V M a bran .py ssu., :LBI
;VrAV ti/ i4
90
Diamondville,.Wyoming
No
.Own
Utah
Maggie Marchello\
22 East 2300 North'
1
CERTIFICATE'. OF DEATH
State File Number: 20100
.Margaret Borino Wilkes
ORMANT INFORM
ame -Tammy Herrmann Relationship:
airing Ada�ess:' 22. East 230 North, Lehi;;
P'OSITION INFORMATION
rr J
Met hod of. Disposition Burial
Pl ace of bisposition: Sandy City Cemetery; San
Dat of Dts osition: February 17;:2010
FU NERAL HOM INFORMATION
Funeral Home: Wing rtuary
Ad dress 118 East Main Street
F uneral'Di'rector: Quinn A;Wrng
M EDICAL CE RTIFICATION
M edical Professional .:Steven B Cherring DO TncityMedical Clinie 2
CAUSE OF:DEATH
cardiorespiratory ;failure`:
congestive heart failure'
Dementia`
Tobacco Use Unknown if:User
Medical Examiner.Confacted No Autopsy Performed No Manner of Death N atural
Date Issued: February 17, 20T0
Utah,84043
Y;: uta
ehi Utah'84
Tirneof Death:
County of Death:
bate •of Birth::
Sex
Marital Status:
Usual Occupation:
Education*:
Father's Narne;
Facility Type:
I IIIIAd II N 1111
17;53
Utah
August;24, 1919
Female'
Widowed
Homemaker
9th'Tp6ugh.120 G rade
Joseph Borino
Home
Daugh
Q0 North, Lindoi
Utah 84042'
;This is•an.exact reproduction of the document registered in the State Office.' of: Vital Statistics.
Security features of. official document include:iIntaglioBorder,;V R images- in:top cycloids,
ultra violet fibers and hologram image of the Uteh'State-.Seal over the Words "State of Utah This
document displays the date, seal and signature ofthe State Registrar and the County/District Health Officer.
6 K
•,Joseph K. Miner; MD, MSPH
Director/Health:Officer
•\County/DistrictHealth •Department
ztiE'" "ts
8sf:
ay
P1 4
y;a
ri
1r.'J R °p °,fir,. �y ns.srr2 +:�:ss siE: y�4� •'t��� :.o �s E i �'e:. 1 ms,�� >��"k•' c p�Mt, ;s
i f t i 1 I [f' ®r 'e ,ie*F41
CERTIFI�CATI AL RED
I
11 vil.11.Wii MILES 1/11 M w.i NI u li i Mil
,;t10 OF HEALTH
TIF ICATE OF DEATH STATE FILE NUMBER
EIARENT'S"
4,ifortt*
DEATh
RACE'AND.i.
EOUCAllON
rl, CATE OF BIRTH (6fa, DaYr9:6
17,1926
ZiFIEVAILV4
1. Yes 1:=1
6b.sNoveAMtEadOrreHssOgrilT.111 A1) tSIA,1,91,:00, give'
L.D.S.:Hospital
i
HOMernaker
15. MOTHER'S NAME PRIOR TO FIRST MARRIAGE (Rrit, Middle,:LasS:
Margaret M. Marchello
16: NAMEMELATJONSHIPBNIWAILING'ADDRESSjOELN,EORMANTIStreetA Alumber, City, State, Zip)
laUrie:f2oberts;.:Dauallter,:;'. 5atnef:;Strest,.,Kemmerer, Wyoming 83101
1.,13),00ATroTIFps FiciN 2
Ji4y 2820
19ICENSEENumew
ME11•10D OF oisppsirigN
L1 00,10W
02. Donation: .0 4. auilet:
16c..L0CAT10N oFiRisfpgriop -,:tit071:1itstaglh
Kemmerer Wyomirig
21.SlGNAft1RE OF FO
f;Y 'i
22: c5FriF1 (Check only.one):r
21. CERTIFYING PHYSICIAN ed ailatime dale and place and due to the cause(s) and manner as slated.
0,2,MEDIC'AL
EXAMINER a4 a's
rv••• tnsIIa(o n my opIllon, death occurred al the time, date, place and due to the cause(s) and manner ae stated;,",
tiri:E: '"i,"-'•-•' //,-..i 1
SIGNATURE 8 'IOU OF BEBilF,IEILI%-,,,77 LIC. NO. 4;3 i DATE SIGNEC
23e. NAME, ADDRESS ANDZIP ..9g71REp7riE:payE oFpEATH (item 24) (Type/Print)
.•r/'
'merle r,r cin14:P.r 4 1 k 0 4 c IT 8 LI
2 DATE DECEASED WAS LASTATTENDED
BY PHYSICIAN 4
■114 .V3;-:g
24. ARIL Enter the chain Of evente-disdaseslrInjeries, 9,1 lietairectly'caesed the drlath. 00 NT enter terminal events such as cardiac erresL resMratory." 1
IMMEDIATE CAUSE (3,)
arrest, or venlr
icelar hbrilIallonwpo'Cit'show169VOILIL l:0.N07413BBEV only ona bause on a line.
leal a,g friCeil t fl' h 1-- t'' 1 a" 0_
Death.' /ir A
.:iipertgirft
r ulting In d th)
disease or condition .,i
esea
ill 1;.. Ype..or 44
Sequentially coaditions,
lit 41
c",•••5pD,Iii ,•,I*-
any, leading .to the ca use •••,a",h
listed on line a: Enter the c, :,e7-',0,•/-4,41:4'
UNDERLYING CAUSE (disease -.1., Eriki(ORAS•fi CONSECILENCE 0F):
or Injury that initiated events." ,.,:c ';'1.3".1",••" 2
PART-II. Other sianiticahl Conditions bbatribaliLliilerchiath' hthe4410e0Inn: Cause given In Part I
-0,V",/,'/I-r/U4r./3 1, Air.?• 1 1. 1 "14 I k 'I c I
41 c.....-il-c- 'lliAfrofii.■.A.ti r ei Al
26 lINN,OUR OP IN 94„2 27I NNEROF DEATH
0:1:Probably contributerig the CaLise"arigriat'h •f] 1.14elinal
0: 21,Wa underlying pau64 If4W Br. ,;;:y• 1 '6:UNKNOWN 03.Suleide
03: old not Coninbutelci ilia be" U
BR
i 4,1s unknoxin in relation to trie hens" 9,
5at .N USER ',.,4".:, e';,/
29a: DATE OF INJURY (MO.,P8X/Y1A.
31in WElitirYRft
re4x4
29t, l (Street or rural 3.. yrif'COUp
20. WAS DECEDENT OF HISPANIC ORIGE412(C444
Precedent!, nor Spenishibldpenbtotiper
Mertes
2. SEX
Female
't "7, an:PLACE OF DEATH (Check only one)
,17,1,,OZOURIIED SOMEWHERE OTHER THAN A HOSPITAL
Lesj6L1HOtheiLon9i;term care fac 06. Decedent's Home 07. Other (specify)
8c." COUNTY OF DEATH
Salt Lake
13d. CITY, TOWN, COMMUNITY, OR RURAL
Diamondville
3a DATE OF DEATH (Mo., Day, Yr.)-.
July 24, 2005
6. BIRTHPLACE (City& State or Foreign Country)
Diamondville
Bd. CITY, TOWN OR LOCATION OF DEATH
Salt Lake City
11. SURVIVING SPOUSES NAME (if wiM, give name prior takrerMarrriege)
13e. RESIDENCE STREET AND NUMBER
601 Diamondville Avenue
7.
13f. INSIDE CfTY LIMITS?
)Yes• 0 2.No
16b. PLACE OF DISPOSITION (name of cemetery, crematory, or other place);
Kemmerer Cemetery
20.,FUNERAL HOME (Name and complete address)
Crandall Funeral Home
,105 E. Center St.
Kamas, Utah 84036
02.
0
S. COulcf Ma be 06.
,Detarmined
25a. WAS AN AUTOPSY
PERFORMED?
21. Yes 2 2. No
factory, office, building, etc. (Specify)
21CDECEDENTS RACE (Chereane or more races fo incdcolo Manta
decedent considered himself or hasoll fo be)
D 02. Black or Africin American
Ei 03.;AgericanIndran or Alaska Native (Name of the enrolled or 017431 tribe)
22a. Was Medical Eiaminer Contacted?,
C]:' 2. No
25b WERE AUT0FSY-FINDINGS-AVAILA8LE
PRIOR TO COMPLETION OE CAUSE OF,
DEATH? 0 Or 2, No
28. IF FEMALE
ig 1. Not pregnant within past year
ID 2. Pregnant at time of death
0 3. Not pregnant, but pregnant within 42 ays ra ea
0 4. Not pregnant, but pregnant'43 clays to 1:yearpatore death
0 5. Unknown it pregnant within the past year
294 PLACE OF INJURY At home, farm street,
29e. If motor vehicle accident
Di Ye D2No 01 Driver flZpass engec; 3; Pedesl riair-
0 4. Olher 0 5. Unknoviii"-
29g. DESCRIBE HOW INJURY OCCURRED (enter sequence of events which resulted in Injury, NATURE OF, INJURY should be
egtered In itam;21)
32. DECEDENTS EDUCATION (Chet:key
v that bar dosalbos the highaf degree or
level of same: cernaeba at the Irmo adverb.)
Zh 2. 9t 121h pride: no 41414144
3. kgh School Graduals orGEOcenipiefed
4. Some cargo cr ea, tt‘di no
4.Asso4iate degree (4.g.. 4.hh4)t'
Do. Bechelorsaagroe
O 7. Master's degree HA;
0 9 Lke;tarcte Le.u., PhD; &ER Riofesirlonie
degree (op., DDS;DVM,119;JDF
34 DATE FILED (Mo:, Day, Yr.)
July 27, 2005::
hiaii5,0,,bertifY:that this is a true copyp)
der; section 26-2-221:of the Co' 9 VoIatet;I:.ibs0As, Amended.
D 05. Japanase
0. 04a1W4Hawatlen 07. FOpino
0 (q4.FM
(II AslerXhicflen
11. Korean
"12. Sertxren 13.1.4erneinese
n 11. Guein4n91n or Chamorro
09. Other PricHc Islander (Spedk)
*5T
k i
e';CifOrflopt6 CrViti4'inIhiS office: This certified copy is issued
ECORDS
By