HomeMy WebLinkAbout979462STATE OF IDAHO
County of Franklin
AFFIDAVIT OF DEATH
KELTON L. LARSEN
979462 11/24/2014 12:30 PM
LINCOLN COUNTY FEES: $21.00 PAGE 1 OF 4
SS BOOK: 843 PAGE: 809 AFFIDAVIT
JEANNE WAGNER, LINCOLN COUNTY CLERK
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The undersigned affiant, the spouse of the late Kelton L. Larsen, hereby deposes
and says:
1. I am the spouse of the above -named individual.
2. The said Kelton L. Larsen died the 18 day of April, 2013, in Preston, Franklin
County, Idaho.
3. The attached Exhibit "A" is a true and accurate copy of the original Death
Certificate of the decedent.
4. On the 14 day of November, 2003, South Ridge Development Corporation,
executed a Warranty Deed conveying certain real property to KELTON L. LARSEN and
LISA J. LARSEN, husband and wife, as Tenants by the Entireties. Said deed was
recorded on the 20 day of November, 2003 as Instrument No. 895440 in Book 542, page
178, in the records of Lincoln County, Wyoming.
5. This affidavit is intended to show that the real property described in Exhibit "B"
attached hereto is now vested fully and completely in your affiant as the surviving spouse
of the decedent.
DATED this 18 day of November, 2014.
16a.
N
LISA J. LAR
SUBSCRIBED AND SWORN to before me this 18 day of November, 2014.
STEVEN B. FULLER
NOTARY PUBLIC
STATE OF IDAHO
NOTARY PUIC for State of Idaho
Residing at: rvec *n
Comm. Expires: 3 1 -1 7
ITEMS 32 30
TO BE USED
OR EXTERN/4
CAUSES ONLY
(COROIdERI
',VA. RESIDENCE STATEOR'FOREIGN COUNTRY
to IDAHO
?d STREET AND NUMBER
..4239 'ST;CUB. ROAD..
'9J A I A TTIME OF OEATH::.
.IB STAN
i c {ti Me(iled•bUt separated I]'_Widuvred:❑•Drror'ded Hm'er01 n(ed 0:0igiridv+ii.
re,
0•EVERIN U FATHER'S NAME:(FIIs4:MIdd10;.Lesl, Sulfi,<)
'"PDRCEST: DONALD AF;TH.4FR
aJ•: ❑Yes 12e.MOTHER'9 MAIDEN NAME (FIrsq.MIEWe, Last SuKa)
a 'a,. FAY DOLOROEGBERT
Q t.,r14,: 1.METH00 OF OISPbSIT10N 16, OP (Nalrle,pnd atltln
000melory 011ie ptg4e)
F••''{ 0 Dona :•.fl Eglombm061 .MAPLETON CEMETE
t0 Removal from Idaho
6 0 Other(Speely) PRESTON, IDAHO
I. 170. SIGNATURE OE FUNERAL SERVICE LICENSEE ORPERSON ACTING AS SUCH I .;ELECTRONICALLY.FILEDt`:JORDAN D.WEBB I
20.FACILITY NAMEH(. ES6adilty,_gNe street ine number),,
4233 EAST CUB RIVER ROAD
1 23. DATE OF DEATH (M IDay/Yr) (Spell month)
v t ,..A prl f 18 2013
42.13A7E OF INJURY(M0/DayfYr)
;(Spell mon1)
April 18, 20 '13,
(36. LOCATIONOF•INJURY: 2 S st ate IDAHO
:'c 3. SOCIAL SEDURICY NUMBER
MALE
6. BIRTHPLACE (City and Slate, Temlory, or Foreign Country)
$/•l,Prf2AMENTO; CALIFORNIA
ECEDENT 130. MAILING ADDRESS (Stroal'ehd Numb'eFr91ty, Slate;,YJp:Cede)
4233 EAST CUB RIVER ROAD PRESTON, ID 83263
ss otcemel y,'..::' 16, )L ME AND COMPLETE ADDRESS OF FUNERAL FACILITY
r 06' F UNERALltOIMIE
005:SOUTH.8b0 EAST
PRESTON:IDAH0,B326
17b, LICENSE NUMBER (011 ii1 LO ,T(1 CAUSE OF OEA4H
M1079..
9est IFDEATH DOCURREDtp A HOSPITALI 196, I:GEATH OCCURRED•SOMEWHERE OTHERTHAN A HOSPITAL:
.1❑Inp llent 2 OER/O toallent3000A '4 ,Q Ho5p)ce fa41115 5Q NuningtlYASe/LOngleim`raref0Ugty 61.Vep¢d§n)s home 70 ON r)Spe0yj
f ,.x.r. TOWN ORLOCATION.OF.PEATN,AND21P000E .22, COUNTY OF :DEATH:
RESTON 10;83263;
::FFt/1NICLIN .i;
24. TIME OF DEATH ma, 2S DATE'PRONbUNCED DEAP(Mo/DayFYr) (Spell month); 20 T(MEPRONOUNCEbD
EsOmated13:36 -14130 April 18 2013 f
G Enter o, 5)i of 010 fl s -0115 Ises, In)udes, ofromplloallano 11'6t4lr6plSY•eaused te01 alh OQ.NQT adlertermina1 events such as cardiac
':hAos1,505p1101 i/ertes0 or1eu10cula without showldg Ne etiology p0NOTABBREVIATE Ehlete■lydge cause on a line:
:x IM :a m o. EOAub n al a SELF INFLIC SHOT 70 HEAb q 0 012 o n ndl)Oe• P. DUE TO (orA5 bonsequenca op c,
�resNgng m deelfi):..:
�Sequentagyllst conditions, b, ?i•: ;Ti!::..: i:' "r "L..
y ',gany, leading to the cause S I DUE TO (or as a consequenee.o¢:' '.t..
on Una a, Enter Ue
'UNDERLYING; CAUSE:':::.rc
O iiAST (01$30ee u¢Injury ;bUEZO.(or es a wnsequenca oD:
41 .I eyenis
Approximate Interval:
Onset to Death
INSTANT
�;PARjiI: Enler,dlher slgnlflcant conditions conMOiiling lh•dee6l but not resulting ln' I h eundedying causpgNen lnParl
Ir rem.r. na nanlwi --P nant43:d, a
s
0 NOtpregUln Past year [(;Nl a
yearbet; or od0610 Y
191 year bora.dea01
0 Pregnant al time of death
0!No. pregnent 0 Unknown i1 pregnantwiWn the past
wth)n42daysafdeaU year
33,TIMEOFINJURY 34. PLACNJU
dnl ,fern, street wnsbuclled site,
(24hr) nurs 0 om 00 aum fa 0 ale) Y.
30 •14.30 I A B A R N AT DEC H
W;1 Street and Numbed *Location 4233 EAST CUB RIVER ROAD
'Ich u_'e'
y37iDESGRIBEHOW INJURY OCCURRED.IF TRANSPORTATION INJURY, STATE THE TYPES(5)OF VEHICLE (S)INVOLyED(AulomoDlla( �p, motordyue, ATV;.e) r7! :;.i
:,SPECIFY )OH VEHICLE DECEDE OCCUPIED If applicable cl'
.OECEDENTSHOT HIMSELF IN HEAD WITIIREVOLVER WNAT SAFETY OEVICES(6) DIO DECEDENT UBEIEMPLOY7
TRANSPORTATION,130a. WAS DECEDENT 0 OriverlOPe(10L ❑Passenger 1 1V6 t
INJURYNLY O r ❑pedesblan i4,J`O(her(S P edy) •OSeatb [i Cl l l l dse50530alj•ielmet ❑Airbag ❑None O Unknown
90 IER CERTIF (00edr only one, based o(rpffiol 1 eapadty fOOSlls ceNp10) 1 0 PHYSICULN l O p0YSICIAN ASSISTATIT f,JADVAlkED PRACTICE P 3 )I¢ LIC
66666 EN E.N M B R
I -To the best of myknneledge, de agroccurred at theSne date,an((p(aee 01144 6loihe al ....(s)/rp f led
99e OATESIGNEO;
-On the basis .Of ooeminellon and/or investigation, In my oplrdon, d ath occurred 0(01e VITO, date, and place end..dile to then e(s)
MM
:?signature and TWa"of Cerilner ►•::ELECTRONICALLY ?SIGNED: DOUGLAS S. WEBB
"Jed. NAME, ADDITES O CODEOP OEsrf (Type QfpiV't)
DOUGLAS S yl)EBB; 109.EAST ONEIDA PRESTON; ID 83263
'1 •eon. HATE 51GNE0::::•.
IDAHO DEPARTMENT :OF:H DiwELFARE
BUREAU OF VITAL\RECORDS AND':HEAL1 1'A,TISTICS;>
DATE FILED;BYSTATE REG)STRABI
04/30/2013
T :DECEDENTS LEGAL NAME (Include AKA's if any) (First, Middle, Lett, Sumo)
jL :r KELTON LEEI:ARSENr r.:;: �rr:Cf'. \l i[.
O 4A'AG6.Lasl Blandey:.f 4b UNDER 1 YEAR 40: UNDER 1 DAY 6 DATE OE BIRTH (MOIDeyIYQ
M5010 I Days Hama 6414100 0811111960
a 52' crow'
7b
I
i40e. REGISTRARSSIGNATUR
•This is a tfap and•' correct;. reproduction of the,0tocument officially registered and placed
on file with::the IDAHO'BUR'EAU .OF VITAL,r•:)RECORDS AND HEALTH STATISTICS.;
DATETSSUED:
This'c6py not Valid u.rsiess prepared on'engraved border
d)splsymg: s1Spah re of the Registrar
n
1, 0‘ 4 WV RV 11 Din 1111I 111111 IrIab
CERTIFICATION OF VITAL RECORD
f.
v
EXHIBIT B
Lot 2 of the South Ridge Ranches Subdivision, Lincoln County, Wyoming as described on
the official plat, filed July 21, 1998 as Instrument Nol 851982 I the records of Lincoln
County Clerk.
SUBJECT, however, to all reservations, restrictions, protective covenants, exceptions,
easements and rights -of -way of record, in sight, or in use.