HomeMy WebLinkAbout885888AFFIDAVIT DING DEATH OF
·
COUNTY OF
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RECEIVED
LINCOLN COUNTY CLERK
john S. Gilchrist, being first
deposes and states as follows:
duly sworn upon his oath,
1. On or about the 25th day of February, 1976,.my father, John
Swainston Gilchrist, a/k/a John S. Gilchrist, died, as is evidenced
by the official certificate of. death attached hereto and
incorporated herein by this reference.
2. At the time of his death, John Swainston Gilchrist owned
an interest with my mother, Elizabeth S. Gilchrist, as tenants by
the entirety, in certain real Property located in the County of
Lincoln, State of Wyoming, and which is more particularly described
as follows:
The Lots Numbered Eight (8) and Nine (9) of the Block
Numbered Fifty-four (54) in the Second Addition to the
Town of Kemmerer, Lincoln County, Wyoming, as surveyed,
platted and recorded.
3. This Affidavit is filed for the purpose of establishing
the fact of the death of said John Swainston Gilchrist and to make
an official.record of the termination of the interest of said
decedent in and to the above-described real property.
DATED this /~ day of ~~ , 2002.
/J~HN S. GILCHRIST
SUBSCRIBED AND SWOR~ to and acknowledged before me this
/~--- day of _/~,)U~~r- ,' 2002, by John S. Gilchrist.
WITNESS my hand and official seal. ~ .
My Co~ission Expires: ~ ~ ;~ ~3~,4,.~ ~[~
2
UTAH STATE DIVISION OF HEALTH
CERTIFICATE OF DEATH
· la'. ~AME' OF 0ECED~NT - FIRST, MIDDLE. LAST ~' · * 2a. DATE OF DEATH - MONTH OAY.'Y"~I~;2b. TIME OF DEATH - ~24 HOUR C~OCKI
John 'SWainS~o~ Gil~h~ ~Februar~ 25. 197.6 ~ 0345
8~,Ot: I * ~'AT COUNTRY 9. s~IAL SECURITY NUMBER i0~ ~1~,. ............... ~IE~,~ lt. N~E OF ~RViVING ~OUSE O~N~jw~Fg EN~.
':~ ~US0],L~ATION , e~V'~ o .K DO E ; 12b. K ND 0F BUS NE~ OR INDU~RY 13: EDUCTION: ~CIFY ONLY .IGHE~ GRADE*COMPLETED
l~ ¥' U~N~ M' T OF WORK NG L~FE E~EN IF RETIRED) j EL~ENTAR% OR ~ECONDARY (~) ~ COLLEGE (1-4 Gl ~*)
: .... '= ~I'~AME' ~ ~ATHER .... ; 15. MAIbEN NAME OF MOTHtR I~S* Was OtCtO~NT tvE. ,N
.'7.T*',~ %~L REEleCt- ,STREE~ ADp. ESS *,..t ,., ' * ' I 17b. INSIDE crrv CORPORATE LIMITS lB, NAME a,~AILING ADD~E~ OF INFORMANT
'"~'" ..... "~ ' ~/' < ' :' ~ Yea jo~ S.'Gil~hrist'
F~.~c ~ %. ,......:;.. ,Ta. coL., , ,7.. s,,,~ 4076 MinUette. circle
:~'~,~=~,~;~'"~.,~ .~ ~. I Lincoln ~ wuomin~ Gran~.:.~eah., 40119
tee ~F t~:-NA~?d~'~b~i!~L..,~,: ~ ~. ,.,.,..~,....O~.......OTH~ ~NST~TUT~ON,. WHE,~ OEAT~ OCCU,,~O ,..~ .. ~ ~Sb. C~TY OR ~OWN. . . . '~ ~. COUNTY
~a~a. ~Q~den M~nQ~ Nurs~q H~ ~ Granq~r ~ Utah
' ' ' 2~. MEDICAL EXAMINER: ']~e~by c~rtJ~ lhat d~ath ¢~cu~d ~ th~ hour, dete & p~'e smJ~d ~. ~b. P~IAN OR MEDiCAL',EX~MINER SIGNATURE II 2Oc. DATE SIGNED
~m lhe causel ~ated 3elow OnE I~t I atte~dtd the d~t~d I'll ~w the decedent I. r ' · ' . ' ' " ~ j LICENSE NO'
~ o,? ~o. tn ..... .-- d.~ . . ~"' -- ~._ ~. ~= Serqe ~. Moore ~ ch~.~_ Medic&l
FICATIOk ',21 F NOT CERTIFIED BY MEDICAg EXAMINER'W~'DEATH REPORTED ~ HIMt Iv-- or ~): ' ' I 2~ CE~T F ER'S ADDRE~ '" -- -- ., ' -
IF YES DATE i HOUR RE~RTED ' / ...... q' '
' " "' ' ' ' ~ I' e4 ~eaxca~ Drive. Salt Lake Citg. Utah
NERAL ,~...1 ~-,,vJ · '" 'I ~ ~ ' 11'24'TannerFUNERAL 'HOME- ~AME AND AODRE~
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26, NAME AND LOCATION OF CEMETERY OR CREMATOSY~ '/~ ' [~. LocA~ REGISTR~uRE ~'" ~ -
, . '. ', · IMMEDIA~ CAUSE:
, . IAI ~O~C ~O~C~O~O~ .' MATE
CDNDITIONS IF ANY r.. ~ DUE TO, OR'A~ A CONSEQUENCE OF ' :'' ' INTERVAL
.~ CAUSE
. .' WHICH GAVE RISE TO I BE~EEN
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OUS TO, OR ~A CONSEaUENCE OF Anp
DEATH. ~R~Yi~ CAUSE
¢1 . .'. DEATH
' ' .": ~9.'.PART ~1. OTHER .SIGNIFICAN~ CONDITIONS- CONTRIBUTI~ TO DEATH, RUT NOT RELATED TO ~E IMMEDiAtE CAUSE GIVEN tn 30a. AUTOPSY 30b tF vZs W.,,
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31, ~=id0m, ~k~, h~., ~lflrmJn~ 1328. DATE OF INJURY(mo.m~,y y.~) ;32b. TIME OF INJURy ] 33. JNJURY AT WORK I 34. PLACE OF INJURY (ipe~i'fy
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35a LOCATION OF NJURY STREET AND NUMBER OR LOCAT ON AND ClT OR *OWN 35b . _ .._ . . [ 3 ' '
INJURY ' ' v o,.,~ ~,o~ ps.c. o~ 36 w.,. ~.bo,.to,v ~,us ~o.. ~o; d,u~ 7 w. · .~ · o,~
iFORMA~ON
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'38. DE~RIBE HOW, INJURY OCCURRED I e [ ' D IN INJURY. NAT E OF JU sHOUL~ aL ~ 3g I mutm'~¢ e ~idem ~ ~y