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Affidavit of Successor Trustee
I, Donald J. Gibbs, being of lawful age and duly sworn according to law, upon my oath, depose and
That under the date September 22, 2008, Robert Byam, as sole owner, by deed of that date, which
deed was duly filed of record in the Office of the Lincoln County Clerk, on September 23, 2008, in Book 7
on Page 397, conveyed to Donald J. Gibbs, Trustee of the Donald J. Gibbs Revocable Trust dated September
18, 1992 and Mary Alice Gibbs, Trustee of the Mary Alice Gibbs Revocable Trust dated September 18, 1992,
the following described property situate in Lincoln County, Wyoming, to -wit:
Lot 58 of Star Valley Ranch RV Park Plat 1 as platted and recorded in the official records of Lincoln County,
Wyoming January 5, 1983 as Instrument No. 589522 and Map No. 292
That by reason of said conveyance aforesaid, Donald J. Gibbs, Trustee of the Donald J. Gibbs
Revocable Trust dated September 18, 1992 and Mary Alice Gibbs, Trustee of the Mary Alice Gibbs Revocable
Trust dated September 18, 1992„ became the owners of the above described land, and title thereto vested
continuously in said trustees from the date of conveyance described in said deed, to the date of death of
Mary Alice Gibbs, on the 4th day of May, 2014. That by reason of and upon the death of Mary Alice Gibbs,
and pursuant to the terms of the Mary Alice Gibbs Revocable Trust Agreement, title to the above described
real property vested in Donald J. Gibbs, Trustee of the Donald J. Gibbs Revocable Trust dated September 18,
1992 and Donald J. Gibbs, as Successor Trustee of the Mary Alice Gibbs Revocable Trust dated September
18, 1992.
Affiant avers and certifies that Mary Alice Gibbs, is the identical party named as trustee 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, the Official Certificate of Death of said decedent, duly
certified by the public authority in which said death certificate is a matter of record.
Dated this day of 4 7' 2014.
State of l ik,i0e11 y
County of Lk Leo I t(\, j ss.
Subscribed and sworn t4 before me, a notary public in and for said County and State, by Donald J.
Gibbs, this 1 t1^- day of S' »-TY 2014.
WITNESS my hand and official seal.
My Commission Expires: G 6
978283 9/5/2014 2:48 PM
LINCOLN COUNTY FEES: $15.00 PAGE 1 OF 2
BOOK: 839 PAGE: 144 AFFIDAVIT
JEANNE WAGNER LINCOLN COUNTY CLERK
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III
Notary Public
County of
Lincoln
NANCY J DANA- NOTARY PUBLIC
State of
Wyoming
'.nv Commission Expires June 25. 2018
1
Arizona
Department of
Health Services
CERTIFICATION OF VITAL RECORD
ANY ALTERATION OR ERASURE VOIDS THIS DOCUMENT
?G6Sfliir.. ".:d� Vii; ^G
X1 DEQ;DEIg S LEGAL NAME- MIDDLE, LAST) 2. AKA'S (IF AN 3. DATE'OF DEATH
Y?
MAR .LICE MAY 04, 20:14
4 SEXf 5 SOCIAL SECURITY NUMBER: 6. DATE OF BIRTH 7. AGE UNDER 1 YEAR. UNDER =1 DAY
8. MONTHS 9. DAYS 10. HOURS 11.:MINUTES
09/17/1930 83
12 PLACE OF -DEATH HOSPITAL: 13. PLACE OF DEATH.- OTHER THAN HOSPITAL: -r
®INPATIENT E R /OUTPATIENT El DEAD ON ARRIVAL CARE NURSING OR LONG TERM RESIDENCE HOSPICE FACILITY ['OTHER 114. FACILITY NAME'(OR STREET ADDRESS IF NOT A'FACIDTY): 15. CITY. TOWN ZIP CODE OR LOCATION OF DEATH: 16. COUNTY OF: DEATH:
IP a i ,!';14.' �II
CAR O`NDELET,•IST MARYS HOSPITAL &HEALTH CENTER TUCSON 85745 I
1i7,a� .Ac AN9 STATE OR FOREIGN COUNTRY) 18. MARITAL STATUS AT TIME OF 19. NAME OF SURVIVING SPOUSE (MAIDEN NAME IF WIFE);
`I 'I
it tl il I f II DEATH: I
IbAS?ER vWY OMING 1 MARRIED DONALD JAMES GIBES
'2D DECEDENTS U SUl�L RESID STREET ADDRESS: 21. CITY AND COUNTY: 22. STATE 23. ZIP CODE 24 EVER IN THE ARMED
q y I: .:V FORCES
130 W AJO WAY'#235 TUCSON, PIMA ARIZONA 85713 NO
2 5-WA S DECEDENIT'OF HISPANIC ORIGIN? 26. DECEDENTS RACES) 1 27. IF AMERICAN INDIAN OR ALASKA NATIVE
f8f NO NOT SPANISH HISPANIC OR LATINO 0 WHITE OTHER ASIAN (SPEC FY) SPECIFY UP So 47A1BES
❑BLACK,
PRIMARY OR:ENROLLED'fAIBE:
AFRICAN AMERICAN
YES 1
MEXICANEXICAN'AMERICAN, CHICANO NATIVE HAWAIIAN
YES PUERTO RICAN 0 ASIAN INDIAN' OTHER PACIFIC' ISLANDER (SPECIFY) ADDRIONAL,TRIBE:
S,
YE CUBAN CHINESE'
YES OTHER (S ECIFY) FILIPINO'
z ❑JAPANESE
❑,GUAMANIAN OR'CHAMORRO' OTHER (SPECIFY) AoomoNALTRIBE
UNKNQWN ;KOREAN
❑;VIETNAMESE ❑UNKNOWN y ADDRIONALT IBE 1'
28UPATION
VI, a, i,.1', b d I �I ❑SAMOAN P�;
EORETARY .I AMERICAN INDIAN'OR ALASKA NATIVE
29 FATFIEg (JAM MIDDLE, LAST) 30.-,MOTHERS NAME (FIRST, MIDDLE:& LAST NAME PRIOR TO FIRST MARRIAGE) l
'.r
1 11 t N�,Il ur l rv' 1 o
31' INFORMANTS NAME 32RELATIONSHIP. 33 INFORMANTS;MAILING(tDDRESS:
D O NALD JA GIBES. SPOUSE W AJ
1302�O`WAY #235, TUCSON, A 857
34 AME AND ADDRESS OF FU FACILITY: 35 FUNERAL DIRECTOR 36. LICENSE
NUMBER-
ADAI FUN ERAL HOMES D 1059'N DODGE BLVD TUCSON;
A JOHN W CHAPMAN;i DIRECTOR F0364
37 ;M OF DISPOSITION: 36. NAME AND LOCATION OF 1st FACILITY 39 NAME AND LOCATION`OF 2nd DISPOSITION FACILITY
x EL ENCANTO MEMORIAL CREMATORY DODGE TU
C ARIZONA NONE y I I I r:
0d l I b ;fit mr I'.i...)) MEDICALE_ RI
CIFlCATdON rfCAUSE
EC (OAfiDEA7tPAHTI..K t i.atr:.irl t!N tlf'tT3„k
)MMEDIA1TE CAUSE.:, 40 A 41 APPROXIMATE INTERVAL r ii
O DEATH
5k ,CARDIAC ARREST UNKNOWN
D UE;TO�OR`AS A 42.8 43. APPROXIMATE INTERVAL:
CONSEQUENCE OF:'.
MYOCARDIAL INFARCTION UNKNOWN
DUETO%OR AS A, 44.0 45fAPPROXIMATEINTERVAL:
CQIJSEQUENCE OF:.
',CORONARY ARTERY DISEASE r UNKNOWN
DUETOiOR AS A 46..0- 47. APPROXIMATE INTERVAL
EQ
CONSUENCEOF_
i ti r ..s,s.'. ry 4� 6A1JSErOF`bEATHYi4A,Ci11.., 9
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING 49. INJURY? 50. INJURY AT WORK? 51. MANNER OF DEATH 52 QF DEATH t?
I THEj UJVDERL ZING CAUSES GIVEN ABOVE: 1.
I ql'' I' NO NO NATURAL DEATH 2
�l III uii II i� tl 53. WAS AN AUTOPSY PERFORMED? 54. WERE AUTOPSY FINDINGS AVAILABLE-T.9' I'
I �I l i li I r COMPLETETHECAUSE OF DEATHI j lli InI
yA gIM IA;:,bY SLIP:IDEMIA, STROKE NO
.a
.CAUS OF:DEATH CERTIFICATION d 3
Certidt'y4�ng PhysicianMurse Practitioner/Physician's Assistant To the best of my 55. NAME OF PERSON COMPLETING CAUSE OF DEATH: 56. DATE CERTIFIED
know`edge death_ occurred due .10 the cause(s) and manner stated.
Medlcai Examiner/Tnbal Law Enforcement Authority On the basis of examination,
andlor,ioVestigation In my 0pinion,:death occurred at the time, date, and place, and
due and manner-stated. KAREN MAUREEN CHANDLER, M.D. 0
7 R 5/06/2014
5 S ADDR 58: NAME OF REGISTRAR: 59.DATE REGISTERED
6 3 7 5'E. TNQ
AUE VERDE `RD., STE. 110 TUCSON, AZ 85715 AUDREY ROGERS 05/08/2014'
ATE ISSUED: 05/12/2014
'ATE` OF ARIZONA
STATE OF ARIZONA
DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS
CERTIFICATE OF DEATH State File NO. 102 2014 01
KHALEEL HUSSAINI
ASSISTANTSTATE REGISTRAR.
This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS,
ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA
;Revised 12/2012:.
This copy not valid unless prepared on a form displaying the State Seal and impressed with the raised seal of the issuing agency.