HomeMy WebLinkAbout886526STATE OF WYOMING
COUNTY OF LINCOLN
)
) ss.
) 886526
AF_F_ID A_V..LT_O~.Fg_ O R S HiP
RECEIVED
'LINCOLN COUI',JTY CLERK
02 m'P 2 6 ~%'"i o. ? S
BOOK C~L?,(.xPR PAGE
I, WARREN W. METER, being first duly sworn, states as follows:
1. That on September 12, 1983, Leisure Valley Inc., conveyed the property
described in the Warranty Deed attached hereto as Exhibit A to WARREN W. METER and
JANET W. METER.
That on June 8, 2002, J'ANET W. METER passed away, a copy of the Death
Certificate is attached as Exhibit B.
3. 'That because of the foregoing, WARREN W. METER has full rights of
survivorship and title to the subject property described in the Warranty Deed attached hereto as
Exhibit A.
DATED this
day of !~evvember, 2002.
,/
STATE OF ARIZONA
COUNTY OF' MARICOPA
)
)ss.
)
WARREN W. METER
The foregoing Affidavit was acknowledged before me by WARREN W. METER this
day of N~vem~r, 2002.
Witness my hand and official seal.
~ LOUISE C. CASBEER I
(~1~/ ~o~ary PubllO- State Of Arizona I
My Commission Expires:
NOTARY PUBLIC
STATE
COPY
STATE OF ARIZONA
STA*E or mZO.A -,
DEPARTMENT OF HEALTH SERVICES - OFFICE OF VITAL RECORDS DEATH N ' I ~
CERTIFICATE.gE DEATH.... ID 102- ~
METER 2. FEMALE JUNE ' 8 2002
AME OF A1 FIRST B, MIDDLE
ECEASED
JANET W.
PACE (e.g., wNte, black, American indian, (spec~/Idbe) et(:.) WAS DECEDENT OF HISPANIC ORIGIN:
SPECIFY: (SPECIFY YES OR NO)
PLACE OF ' A. COUNIY I B. TOWN OR CITY
DEATH
I MARICOPA I GLENDALE
DATE OF MONTH DAY YEAR AGE (YEARS
BIRTH LAST BIRTHDAY} MOS. DAYB
i:z: SEPTEMBER 20 '~.1919 82
(Ii nol in USA, n~ma counlry)i CITIZEN OF WHATSP~[CIFY
COUNTRY?
I ~ ~ , BROOKLYN', NEW YOR~ ' I. U'S'A'
A. Sinlt= . B. COUNTY C.TOWN OR C TY
RESIDENCE
ARIZONA FL~RICOP~
.~ITY LIMITS?
!,45445E. W. PORT AU PRINCE LANE
YES
FATHER'S A. FIRST B. MIDDLE
NAME .
~,~ ~ I BURCHARD A.
~:'i~J'FORMAN?SS~5)~'[U.,~ M~LViN W.
I~'II~URIAL, cREU~TION, J DATE
~l]J~-. REMOVAL, OTHER {Spe~Jly
J~[~ F~NERAL HOME ' NAME
FUNERAL SERVICES, INC.ii
AND TITLE
DATE SIGNED (Mo.,
iF YES, INDICATE MEXICAN, SPANISH, PUERTO RICAN, (SPECIFy YES OR NO)
CUBAN, ~ClI was DECEASED EVER IN u'S' ARMED FORCES?
Cl ' ~ , NO
C. HOSPITAL OR (IF RESIDENCE, GIVE STREET ADDRESS)
'",. ~ISTITUTION D~] OOA
BRICK MANSION CARE HOME mop EMER.
· I '~] IN PATIENT
IF UNDER 1 DAY MARRIED, NEVER MARRIED, SURVIVING (iF WIFE, GIVE MAIDEN NAME}
HRS, MIN. WIDOWED,MARRIEDDIVORCED (SPECIFY) . SPOUSE . ' WARREN. W, /
c. ~. ~o, METER
SOCIAL SECURITY NO. doneUSUALrno~tOCCUPATION'o! v,~Jdong ~,e,(GIveevenklndlf ieflred)bl w~fk KiND OF BUSINESS OR INDUSTRY
068-16-4012 ~4A. HOMBMAKER ia. OWN HOMBl
~l ZIP CODE HOW LONG tN ARIZONA? EDUCATION
..HIGHEST GRADE COMPLETED
31 YEARS
PREVIOUS STATE ELEMENTARY-SECONDARY I COLLEGE
OFI~_ SlDENCEI~:. ;'~_ (0-12) J S, 5+ (1-4 or 5 +)
B. MIDDLE C, L~ST
DEWAR
ADDRESS ',. CITY AND STATE ZIP CODE
''' lI
.... W!. PORT GLENDALE, ARIZONA 85306
NAMFJLOCA~rlON ' ~. C ,p~MATORY CERT. NO.
g as such (SIGNATURE)
)ZINAS sF .109%
IN MY OPINION DEATH OCCURRED
, AND MANNER STATED·
?': ti ;~ ~ flOUR OF DEATH i
PRONOUNCED DEAD
DATE REC'D. IN STA?E OFFICE
NAME AND ADDRESS OF CERTIFIER
-367 EAS~
REG. FILE NO.
12594.
A, IMMEDIATE CAUSE (FINAL DISEASE
MATE
BETWEEN
ONSET
: PART II. Other slanlfican( conditions contributing to death I~ut not resulting in the u. nderlythg cause given In Part t
~8.
~.IANNER OF DEATH DATE OF MO DAY YR HOUR INJURY AT WORK? , DESCRIBE
(54SIietJty Yes or No)
E]~-C~Om* [] ~NyESTta^TION PLACE OF INJDRY (At home, farm, alreel lac(Dry, office building, el(:.) WHERE LOCATED?
SPECIFY
AUTOPSY WAS CASE REFERRED TO MEDICAL EXAMINER
(Specify Yes or No) (Specify Yes or No)
4~. NO I o.YES, FOR CREMATION
HOW INJURY OCCURRED
STREET ADDRESS , CITY OR TOWN STATE
CERTIFIED coPy'oF VITAL RECORDS
STATE OF ARIZONA ] I' June 26,2002 l
COUNTY OF MARICOPA ~ SS DATEISSUED : ~ '.,/' . ,' '
This is a t,'UB end exect reproduction of the do¢,ment o;-"ioially reglatered and pi~ce~/ .I.,~/.~'~-~ [~// / 7 '
on file in the VITAL RECORDS SECTION, DEPARTMENT OF HEALTH SERVI(~f~
PHOENIX, ARIZONA Isaded under the authority of A.R.S. 36-34:1, end by direction of: '\\ ' J~at~an S, Wel~buch, M.D.
' -. ~ County R~91strar
Of Public HeaRh
This copy not valid unics~ prepared o~ engraved border displaying coun[y seal in color and raised seal of issuing agency.