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LINCOLN COUNTY FEES: $18.00 PAGE 1OF 3
BOOK: 842 PAGE: 240 AFFIDAVIT
JEANNE WAGNER, LINCOLN COUNTY CLERK
I 1111111 11111111111111111111111 III 11111111 11111 I I I I I I I I I I I I 1111 II 1111 1111
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, LAK.EVIEW ESTATES SUBDIVISION, according to the official plat recorded in the Lincoln
County Clerks office, Lincoln County Wyoming, Plat No.157
Tax Roll No. 12- 3718- 29 -3 -08- 048.00
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Dated this clay of
(2014A.D
2 d'd CCJ2y
SHARLEEN STOOR
INDIVIDUAL ACKNOWLEDGMENT
STATE OF
SS
County of C v-
On the day of C olo-e.s` A.D. 2014 personally appeared before me SHARLEEN
STOOR the signer(s) of the within instrument, who duly acknowledged to me that she executed
the same.
Commission expires:
Residing in: 1,)
N.t.'ry Public
JANELLE BLACKWELDER
Notary Public
State of Idaho
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SIX S
SOCIAL SECURITY NUMBER A
AGE D
DATE OF BIRTH
I
BIRTHPLACE P
PLACE OF RESIDENCE
MARITAL STATUS AT TIME OF DEATH N
NAME OF SURVIVING SPOUSE (1/Itifs, maiden name) W
WAS DECEDENT EVER IN
U.S. ARMED FORCES?
FATHER NAME B
BIRTHPLACE
MOTHER MAIDEN NAME B
BIRTHPLACE
METHOD OF DISPOSITION W
WNERAL. SERVICE LICENSEE
<s
NAME AND ADDRESS OF FUNERAL FACILITY
DATE OF DEATH T
TIME OF DEATH C
CITY,TOWN OR LOCATION OF DEATH C
COUNTY OF DEATH
CAUSE OF DEATH (underytng cause leer) Appto cot and imaDaelh te Interval Between
e On
PULMONARY FIBROSIS 12 YEARS
DUE TO (or as a consequence of):
D.
DUE TO (w es a consequence d):
DUE TO (or es a consequence ol):
d.
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH but not resulting In the underlying cause given snow W
WAS AN AUTOPSY
PERFORMED?
?I
MANNER OF DEATH N
NAME OF CERTIFIER!:.. T
TITLE
CORONEFI.SUPSEQUENT CERTIFICATION IF NECESSARY.
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Date Filed
DECEDENT LEGAL NAME
JULY 25, 2014
GARY LYNN STOOR
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STATE OI+
IDAHO DEPARTMENT H EALTH AND.WELFARE
BUREAU OF VITAL•.FtECORDS :AND HEALTH STATISTICS
CERTIF.ICATh OF DEATH
TIME OF INJURY
DATE OF INJURY
LOCATION WHERE INJURY OCCURRED
DESCRIPTION OF HOW INJUR,' OCCURRED
PLACE OF INJURY.
:JULY 25
DATE ISSUED:
This Is a Irue and correct reproduction of the document officially registered and placed
an file withlhe IDAHO BUREAU OE VITAL.RECORDS AND HEALTH STATISTICS.
This copy not valid unless prepared on engraved border
7 displaying state seal and signature.ol the Registrar.
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JAMES B. AY. DELOTfE
STATG REGISTRAR
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