HomeMy WebLinkAbout97879264165
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Tax Roll No. 12 -3 619- 09.4 -2- 003..00
978792 10/14/2014 12:02 PM
LINCOLN COUNTY FEES: $18.00 PAGE 1OF 3
13001K: 841 PAGE: 251 AFFIDAVIT
JEANNE WAGNER, LINCOLN COUNTY CLERK
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AFFIDAVIT
I, JOHN H.EVANS III, being fast duly EW.0111 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 UTAH
That I was well and personally acquainted with DULCIE W. EVANS, also known as
DULCTR B. EVANS one of the Trustees of •the JOHN I EVANS III AND DULCIE 13. EVANS
FAMILY TRUST AGREEMENT OF JULY 23, 1984 in that certain QUIT CLAIM DEED dated
July 23, 1984 and recorded August 2, 1984 in Boots. 217P,R at Page: 6 as Filing No, 620302
in the office of the Recorder of Lincoln County, Wyoming.
That 1 know of my own knowledge that DULCIE I3, EVANS in the said deed and
DULCIE W. EVANS mentioned in the attached Certified Copy of Certificate of Death was one
and the same person,
This affidavit is intended to terminate the Trusteeship of said DULCIE B. EVANS, as
Trustee of the JOHN 1-1. EVANS III AND DULCIE B. EVANS FlUvIILY TRUST
AGREEMENT OF JULY 23, 1984 said Trust in the following described property:
Lot Number 16 o1.' Alpine Retreat Subdivision No. 2 as platted and filed in the Lincoln Comity 'Clerk's
Office. Subject to those Covenants and Restrictions as recorded in Book 96 PR, Page 549, Kemmerer,
Wyorciag.
LFI
64165
Dated this
c.
day of nitro bey 2014 A.D.
INDIVIDUAL ACKNOWLEDGMENT
STATE OF U
SS
County of St/ tci«
On the 3 day of p I A.D. 2014 personally appeared before me JOIN R.
EVANS 111 the signer(s) of the within instrament, who duly acknowledged to inc that he
executed. the same.
Co1111iISSi011 expires: Feb 1 1,
NOTARY PUE3UC
DUSTIN JOHN HUMRICH
074731
COMMISSION EXPIRES
FEBRUARY 17, 2018
STATE OF UTAH
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CERTLEICATION O FVITAIL•: RECORD
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DECEDENT INFORMATION
Date of Death:
City of Death:
Age:
Place of Birth:
Armed' Services:
Spouse's Name:
Industry/Business:
Residence:
,Mother's Name:
Facility or Address:
INFORMANT INFORMATION
Name: John H Evans Relationship: Souse
Mailing Address: 3204 East: Deer Ridge Place, Sandy, Utah 84092
Date Issued: December 16, 2010
Barry E. Nangle
State Registrar
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December 8, 2010
Sandy
80
London, England
No
John H Evans
Own home
Sandy, Utah
Nellie Florence Wilson
3204 East Deer Ridge Place
DISPOSITION INFORMATION
Method of Disposition: Burial
Place of Disposition: Wasatch Lawn Memorial Park, Salt Lake City, Utah
Date of Disposition: December 14, 2010
FUNERAL HOME INFORMATION
Funeral Horne: Wasatch Lawn Mortuary
Address: 3401 South Highland Drive, Salt Lake City; Utah 84106
Funeral Director: Daniel F Seron
CAUSE OF DEATH
Cor Pulrrmonale [Onset, 10 Years]
Due to (or as a consequence of); Pulmonary Hypertension [Onset: 10 Years]
Other significant conditions: Diabetes, Chronic Kidney Disease
Tobacco Use: Non -user
Medical Examiner Contacted: No Autopsy Performed: No Mariner of Death: Natural
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CERTIFICATE OF DEATH
State File Number: 2010014103
Dulcie Wells Evans
tIII i IIIlII
Time of Death:
County of Death:
Date of Birth;
Sex:
Marital Status:
Usual Occupation:
Education:
Father's Name:
Facility Type:
111
*062 672960*
NV AIL E x 411 0 ERASUFt VO 'THIS CE IFICATE
22:30
Salt Lake
June 10, 1930
Female
Married
Homemaker
Bachelor's Degree
Lawrence William Wells
Home
MEDICAL CERTIFICATION
Medical Professional:. Philip Roberts M D, 10965 So. State Street, Suite 100, Sandy (Salt Lake), Utah 84070
This is an exact reproduction of the document registered in the,State Office of Vital Statistics.
Security features of this official document Include: Intaglio Border, V R images in top cycloids,
ultra violet fibers and hologram image of the Utah State Seal, over the words "State of Utah
This document displays the date, seal and signature of the State Registrar of Vital Statistics.
UTAH DEPARTMENT OF HEALTH
Office of Vital Records Statistics
Salt Lake City, Utah
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