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Hickman
jandfitleCo
SINCE 1904
979006 10/24/2014 11:57 AM
LINCOLN COUNTY FEES: $18.00 PAGE 1OF 3
BOOK: 842 PAGE: 103 AFFIDAVIT
JEANNE WAGNER, LINCOLN COUNTY CLERK
11111111111111111111111111111111111111111111111 1 111111 I I I I I I 1 111111111111111111
AFFIDAVIT
I, SHARLEEN STOOR, being first duly sworn 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 IDAHO
That I was well and personally acquainted with GARY L. STOOR, one of the Trustees
of THE STOOR FAMILY TRUST in that certain QUIT CLAIM DEED dated October 30, 2008
and recorded November 3, 2008 in Book:708, at Page: 370, as Filing No. 943369, in the office of
the Recorder of Lincoln County, Wyoming.
That I know of my own knowledge that GARY L. STOOR in the said deed and GARY
LYNN STOOR 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 GARY L. STOOR, as
Trustee of THE STOOR FAMILY TRUST said Trust in the following described property:
Lot 313, LAKEVIEW ESTATES 6th Addition to the Town of Alpine, as recorded in the office of the
County Clerk of Lincoln County, Wyoming, recorded May 6, 2003, as Receiving No. 889776, as Plat No.
121 -G
Tax Roll No. 12- 3718- 29 -3 -08- 048.00
LH
64157
Commission expires: /7 /a°
Residing in: C.C5 k
Dated this day of
2014 A.D.
_S
SHARLEEN STOOR
INDIVIDUAL ACKNOWLEDGMENT
STATE OF o o
SS
County of 3u'
On the 1 day of A.D. G`aol-es`' 2014 personally appeared before me SHARLEEN
STOOR the signer(s) of the within instrument, who duly acicnowledged to me that she executed
the same.
N Public
JANELLE BLACK(WELDER
Notary Public
State of Idaho
LH
SIX
MALE
SOCIAL SECURITY NUMBER
AGE
:83 YEARS
DATE OF BIRTH
JUNE 05, 1931
BIRTHPLACE
CONDA, IDAHO
PLACE OF RESIDENCE
SODA SPRINGS,
IDAHO
MARITAL STATUS AT TIME OF DEATH
MARRIED
NAME OF SURVIVING SPOUSE (W Nita, maiden namo)
SHARLEEN COX
WAS DECEDENT EVER IN
U.S. ARMED FORCES?
YES
FATHER NAME,
VERN STOOR
BIRTHPLACE
IDAHO
MOTHER MAIDEN NAME
JENNIE AVEREL
BIRTHPLACE
IDAHO
METHOD OF DISPOSITION
BURIAL
FUNERAL SERVICE LICENSEE
DARRIN .F.. SIMS
NAME AND ADDRESS OF FUNERAL FACILITY
SIMS FUNERAL HOME, SODA SPRINGS, IDAHO
DATE OF DEATH
JULY 24, 2014
TIME OF DEATH
1:10 A.M.
CITY,TOWN OR LOCATION OF DEATH
SODA SPRINGS, IDAHO
COUN1Y OF DEATH
CARIBOU
CAUSE OF DEATH (underlying cause est)
a.
PULMONARY FIBROSIS
Appro:inwla Interval Selman
Onset and Doalh
12 YEARS
DUE TO (or as a consequence of):
b.
DUE TO (or au a consequenco of):
c.
01.IE TO (or as a consequence o0;
d.
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH but not resulting in the underlying cause given above
CORONARY ARTERY DISEASE, HYPERTENSION
WAS AN AUTOPSY
PERFORMED?
NO
MANNER OF DEATH
NATURAL
NAME OF CERTIFI ER
JOHN K:','FRANSON, M. D.
TTTLE
PHYSICIAN
CORONER•SUBSEQUENT CERTIFICATION IF NECESSARY
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}..I .k F.t rc
DATE OF INJURY
TIME OFINIURY
PLACE OF INJURY'
INJURY AT
LOCATION WHERE INJURY OCCURRED
4
if
itt
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Date Filed
DECEDENT LEGAL NAME
TIFY:CATIO ',a.F:VI'AL F
JULY 25, 2014
GARY LYNN STOOR
DESCRIPTION OF HOW INJURY OCCURRED
CERTIFICATE OF DEATH
This Is a true and correct reproduction of the document officially registered and placod
on file with the IDAHO BUREAU OF•VJTAL,RECORDS AND HEALTH STATISTICS.
JULY 25'; :.2:014
DATE ISSUED-
X•Wt•i.,t,I Y'!•Y•YiA
STATE OF
IDAHO DEPARTMENTO.F HE
BUREAU OF VITAL.RECORDS AND HEALTH STATISTICS
This copy not valid unless prepared on engraved border
displaying state seal and signature of the Registrar.
f�`r i4rtriC
N .t fti.W .r.P?YV 's t 1 a �t„o 0 0
JAMES B. AIYDELOTI`E
STATE REGISTRAR
�r
to to I
Stale File No.
2014 -06817
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