HomeMy WebLinkAbout978537STATE OF UTAH
COUNTY OF DAVIS
I, Max D. Woolverton being of lawful age and duly sworn according to law upon my oath
and depose and state:
1. That I am of adult age, a resident of Mountain Home, Idaho, and the Affiant herein.
2. That by virtue of the conveyance which is recorded in the Office of the Clerk for Lincoln
County, Wyoming, located at Kemmerer, Wyoming in Book 319PR, Page 548 is
recorded a Warranty Deed dated October 22, 1992, which conveys unto Max D.
Woolverton and Gladys I. Woolverton, joint tenants, the following property more
particularly described, to -wit:
Commission Expires:
Lot 4 of Star Valley Ranch Plat 15, Lincoln County, Wyoming as described
on the official plat filed as Instrument No. 514466 of the records of the
Lincoln County Clerk.
3. That said Gladys I. Woolverton died on the 17th day of June, 2014, and a copy of the
original certificate of death, certified to an a true and correct by public authority in which
the original of said certificate is a matter of record, is attached hereto as Exhibit "A
4. That by reason of death of said Gladys I. Woolverton and by reason of state statutes, the
decedents interest and title in said property has terminated and title to the real property
conveyed thereby has vested absolutely in Max D. Woolverton continuously since the
death of the said decedent.
FURTHER AFFIANT SAYETH NOT.
ss.
Witnessed my hand and official seal.
AFFIDAVIT
The foregoing instrument was subscribed and sworn to before me by Max D. Woolverton
this 21) day of September, 2014.
2.0/S,2di
978537 9/25/2014 10:49 AM
LINCOLN COUNTY FEES: $15.00 PAGE 1 OF 2
BOOK: 840 PAGE: 173 AFFIDAVIT
JEANNE WAGNER, LINCOLN COUNTY CLERK
IIIIIII IttII IIII IIIIII !IIII II II 1 III IIIII 1111! IIIII IHII HH IIII II 1 III (II! IIII
Notary Public
NOTARY PUBLIC
LOSE 1 I E COLE
659899
COMMISSION EXPIRES
NOVEMBER 9, 2016
STATE OF UTAH
ry
CERTIFICATE OF DEATH 201401353
STATE OALBNUMBBA:::::::::;.
QFPPE�tth
rar,
"91111111ffik A-Tit
WOOLVERTON."
3b:•CITY, TOWttOR LOCATION:ig.::DEATq
Elko
White
90: OF BIRTH:IIf flot
fyailf
13SOCIAL SECURITY NUMBE:f
45ei RSIDEN9E:STATE
18a. INFORMANT- NAME (Type or Print)
Patty LOVELAND
ALNREMATION:MOVAL. OTFIERISPegy),
re:Met
:20a.T.LINEME DIApTO:SIGNATURE
JASON
SIGNATURE
TRADEpALL -NAME AND ADDRESS
21a. TOlhe bEiatt:Of.:dfy knowledge4eathoccurred *the tpe, date encl. placcrand
1 3 5 Iwe tiftlife cause(s) qate):1,'
211;CDATE•:.SIONEO(MO/Oay/yry7 21c. HOLIR.:OF:DEATH
r--21d. NAME OF ATTENDING 'PHYSICIAN IF OTHER•THAN CERTIFIER-
17k-ion (Type or Print)
24altEGISTNNR:pignatuta)
NIPOLEfSH
Si ONAT.URg AUTHENTIPATEPW.
81:6•ACC., SUICIDE.
OR PENDINO
28e, INJURY. ATMORK (Specify
oa either, glya:street:
nf number)
1811 CanYon:Drive:-..•
6. Hispanic Origin? Specify
No Non-Hispanic
911C1TIZEN9F WHAT COUNTRY
14USUAVOCQIJPATION of,i1.1y.brk.DPne Ddring Mat:
of Workinglife,'Even If RetIred)„ Homemaker
i. couNTY
gsk,..DA78.•.giNJ9:ty:
19:PDPP1
12
7a. AGE
birthday (Years)
83
15c. CITY, TOWN OR LOCATION
2. DATE OF DEATH (Mo/Day/Year)
17, 204
7b. UNDBR YEAR
MOS' I DAYS)
11.MARRIEO; MARRIED,MIDOWED, 112. SURVIVING SPOUSE (if wife, give
DIVORCED-ppally) Married:
.maidennarile). Max WOOLVERTON
17;:MOT.HER/pARENT•NAIME (First-Middle Last Suffix)
Cleve IIAPER
18b.MAILING ADDRESS: State;
#3:Eike:;-NeVada:t§8cd::::::
19b. ,CEMETERY OR'CREMATORYi, NAME,
Sunset Crematory
20b.FUNERAL'
DIREPPRPPENSE
.gee:
28f. PLACE OF INJURY- At home, farm, street, factory office:: building, etc. (Specify)
39..:IftIOSp., Or lat.:: indiCata
Ini*fengsPecb
it.::::
::::Home
7c..:UNDER 1 DAY
HOURS
14b. KINO.:OF:t3DSINESS ORMQUST
15d. STREET
1811 Canyon Drive
206::::NAMEANO.ADORESS 'OFFACILITY
P 0 BOX Elke:AW":4980t:
'22a .0filhesbasIs oteXaminat(On:and/orlfivestigatIon in my opiplcirP.tleath:acurr3ittiat:::.:.:
•ci 0 the tiritd, date and place and due to the!cause s) gated.
SIGNATURE AUTHENTICATED
:W 22D.
0 z .1: August 25:;'
AND ApPRESS 06120Ai■OPV0f1:COIVI■IPF) TI;j(Piioi(pelbt)
Willtam RO Silver Street E
2.3i NA.
24b.,DATE RECEIVEWREOISTA2ARg•
(Mo/Day/Yr) August 25 2014
w.41FicANT.:10N.P.9:101■10:DociditiPn.".sqntributfogte:death:butnotreetilting Inlhe undeflying cause given in Part 1.
3a. COUNTY OF DEATH
Elko
4/:SEX
Female
g:DATE:OF BIRTHSMOIDay/Yr)
•••••:dunetI:1031
Ever in 1.)$Arfrie
Forces?:::
15e. INSIDE:01y
LIMITS (SPeelly*Yes
or No)
19C ori•TPwrig:::Atqt
Elko Nei 89803
HOUR OFDEATFL
22
1
23b.
:24c. TO COMMUNICABLE DISEASE
YES' W..: NQ
25. IMMEDIATE CAUSE ONLY CAUSE :PER:LINE:F01 (c).)
PAR1I Lou h 9 "iDiseade
r
DU.S•TO, OR AS.:8 coNsE9ws.N12F:,.::-.
DUE TO, OR AS A CONSEQUENCE OF:
(d)
TO, OR AS.A:SONSE011ENSE
(c)
Interval onset and:treatV
erval betuyee6•OnS4t and death
Af Interval CetweartonseLand death.
26. AUTOPSY
(Specify Yes c(
27. Viiii§tASE REFERRED
TO CORONER (Specify Yes
or No) Yes
o66ORIBE•tiOw iwuRroCCuRR
26g. LOCATION
sT5g§:.r OR •:::,ITY:OR TOWN
LACK
IECEDENT
::.10
fOURREfii'ilt.
OSTITUTRSN''
iE.HANDBOOK
REGARDING ''y
)MPLETION
-46.-FATHER/BARENT.: NAME (Ftypt...."..Middlt.:::Last.:
PAR SHIS h T UCKER
3POSIT[ON
(ADE CALL
CE REIITER
;EGISTRO
CAUSE: OF
ANY-WHinik
simaoiATE::
r-cAuss
;1:ATING.TRE
q LJ A:Ti
•s•Vrime:74 illiGa1219 A Th. N iiii IIP
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w 9PTCiffilileATio: firiffeliiiiiik'
N.
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441
STATE REGISTRAR
C CQ VITA
Th)S:ig:true and exa'otteproduction of document officially registered and
gacedititti:fildM.The'hfficeifilthe State Oegistfg::anO Vffel;I3ecords.:
i:- l..sER 2914 S.141.T.ERGISTF3AR
PA7PSSUE
This copy is not valid unless prepared on engraved border disnfaying date sdal and signature of Registrar
e
VRS-Rev-20120523a
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114
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